What are the initial treatment options for a patient presenting to the emergency department with severe symptoms?

Initial Emergency Department Management of Severe Presentations

For patients presenting to the ED with severe symptoms, immediately implement the ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach with simultaneous assessment and treatment, prioritizing airway patency, oxygen delivery to maintain saturation >90-94%, IV access, and rapid identification of the underlying life-threatening condition. 1, 2

Immediate Assessment and Stabilization (First 10 Minutes)

Primary Survey - ABCDE Approach

Airway Assessment:

• Determine if the airway is patent by looking for ability to speak, abnormal sounds (stridor, gurgling), or complete obstruction 1, 3
• If compromised, perform immediate airway maneuvers (head tilt-chin lift, jaw thrust) and consider advanced airway management 4, 5

Breathing Evaluation:

• Measure respiratory rate, oxygen saturation, and assess work of breathing (use of accessory muscles, inability to speak in full sentences) 2, 1
• Administer supplemental oxygen immediately if saturation <90-94% - this is a Class I recommendation across multiple conditions 2
• For severe respiratory distress, consider non-invasive ventilation early, which has 80-85% success rates in acute respiratory failure 6

Circulation:

• Obtain vital signs within minutes: blood pressure, heart rate, temperature, and assess perfusion (capillary refill, skin temperature, mental status) 2, 1
• Establish IV access immediately and draw blood for complete blood count, coagulation studies, glucose, and troponin 2
• Initiate continuous cardiac monitoring to detect life-threatening arrhythmias 2

Disability:

• Perform rapid neurologic screening including level of consciousness, pupil response, and focal deficits 2
• Check blood glucose immediately - hypoglycemia is rapidly reversible and must not be missed 2

Exposure:

• Fully expose the patient to identify injuries, rashes, or other physical findings while maintaining temperature control 1

Condition-Specific Initial Treatments

Acute Coronary Syndrome (Chest Pain)

For STEMI or high-risk presentations:

• Administer aspirin immediately unless contraindicated 2
• Give nitroglycerin 0.4mg sublingual every 5 minutes (up to 3 doses) if systolic BP >90 mmHg and patient has not taken phosphodiesterase-5 inhibitors within 24-48 hours 2
• Caution: Avoid nitrates in suspected right ventricular infarction (obtain right-sided ECG for inferior STEMI) 2
• Administer IV morphine for persistent pain unresponsive to nitroglycerin, though use cautiously in NSTEMI due to registry data showing increased mortality 2
• Obtain 12-lead ECG immediately but do not delay CT scan if stroke is also being considered 2

Acute Stroke

Time-critical management:

• Administer oxygen only if saturation <94% - routine oxygen is not indicated 2
• Do NOT treat hypertension in the prehospital/early ED setting unless systolic BP <90 mmHg (hypotension requiring support) or patient is a candidate for thrombolysis 2
• For thrombolysis candidates with BP >185/110 mmHg, use labetalol 10-20mg IV over 1-2 minutes (may repeat once) or nicardipine IV starting at 5mg/hr 2
• Order emergent non-contrast CT scan immediately - this takes priority over most other tests 2
• Verify time of symptom onset or last known normal through witnesses/family 2

Acute Heart Failure

Based on blood pressure and congestion:

• For hypertensive AHF (SBP >140 mmHg, which represents 60-77% of ED presentations): Initiate vasodilators immediately - IV nitroglycerin or nitroprusside 2
• Administer IV loop diuretics (furosemide) for volume overload 2
• Oxygen therapy based on clinical judgment unless saturation <90%, then give routinely 2
• For respiratory distress, initiate non-invasive ventilation immediately - this reduces mortality and intubation rates 2
• Monitor respiratory rate, blood pressure, heart rate/rhythm, urine output, and peripheral perfusion continuously 2

Severe Asthma Exacerbation

Severity stratification guides treatment intensity:

For severe exacerbation (PEF <40% predicted, unable to speak in sentences, respiratory rate >25):

• Administer high-dose inhaled short-acting beta-agonists (albuterol/salbutamol 5mg) via nebulizer every 20 minutes for 3 doses 2, 7
• Add ipratropium bromide 0.5mg to nebulizer - this reduces hospitalization rates in severe exacerbations 2, 7
• Give systemic corticosteroids immediately (oral prednisone 40-60mg or IV methylprednisolone) 2, 7
• Oxygen to maintain saturation >90% (>95% in pregnancy or cardiac disease) 7
• For life-threatening exacerbation (PEF <25%, minimal response to bronchodilators): Consider IV magnesium sulfate 2g over 20 minutes 2, 7

Critical pitfall: The presence of drowsiness predicts impending respiratory failure - immediately transfer to facility with ventilatory support capability 2

Anaphylaxis

Immediate life-saving intervention:

• Inject epinephrine 0.3-0.5mg (0.01mg/kg, max 0.5mg) intramuscularly in the mid-outer thigh immediately upon recognition - this is the single most important intervention 2
• Repeat epinephrine every 5-15 minutes if inadequate response (6-19% of patients require second dose) 2
• Place patient supine with legs elevated unless respiratory distress/vomiting present 2
• Administer supplemental oxygen and establish IV access 2
• Do not allow patient to stand or walk - sudden position changes can precipitate cardiovascular collapse 2

Suspected Aortic Dissection

High-risk features requiring immediate action:

• Abrupt/instantaneous onset of severe, tearing/ripping chest or back pain 2
• Pulse deficit, BP differential >20mmHg between limbs, new aortic regurgitation murmur 2
• Treatment priorities: Pain control and blood pressure reduction with target heart rate <60 bpm and systolic BP 100-120 mmHg 2
• Start IV beta-blockers FIRST (before other antihypertensives) to prevent reflex tachycardia 2
• Critical: Withhold all antithrombotic therapy - do not give aspirin, heparin, or thrombolytics 2

Monitoring and Reassessment

Continuous reassessment is mandatory:

• Repeat vital signs and focused examination every 15-30 minutes initially 2
• For respiratory conditions, repeat oxygen saturation and arterial blood gases 30-60 minutes after initiating therapy 6, 7
• Serial lung function (PEF or FEV1) at 1 hour is the strongest predictor of hospitalization need in asthma 2, 7
• Cardiac monitoring for first 24 hours in stroke patients to detect atrial fibrillation 2

Critical Pitfalls to Avoid

• Never give high-flow uncontrolled oxygen to COPD patients - target saturation 88-92% to prevent CO2 retention and worsening acidosis 6
• Do not use calcium-containing IV solutions with ceftriaxone - precipitation can occur, especially dangerous in neonates 8
• Avoid treating hypertension in acute stroke unless patient meets thrombolysis criteria or is hypotensive 2
• Do not delay epinephrine in anaphylaxis - antihistamines and steroids are adjunctive only 2
• Never give thrombolytics if aortic dissection is suspected - this is uniformly fatal 2