What are the initial steps in managing emergency medicine situations?

Initial Management of Emergency Medicine Situations

The initial steps in managing emergency medicine situations follow the ABCDE approach (Airway, Breathing, Circulation, Disability, Exposure), with immediate focus on airway patency, oxygenation, and circulatory support, while simultaneously activating emergency response systems and beginning diagnostic work-up. 1, 2

Immediate Assessment and Stabilization

Primary Survey: ABCDE Approach

Airway Management

• Immediately assess airway patency by looking for chest rise, listening for breath sounds, and feeling for air movement 1, 3
• Open the airway using head-tilt/chin-lift or jaw-thrust maneuvers if cervical spine injury is not suspected 1, 2
• Remove visible obstructions and suction if necessary 1, 4
• Administer 100% oxygen via non-rebreather mask or bag-mask ventilation if breathing is inadequate 1
• Intubate the trachea if airway cannot be maintained or patient requires prolonged ventilation 1, 5

Breathing Assessment

• Evaluate respiratory rate, depth, symmetry, and work of breathing 2
• Auscultate lung fields bilaterally for air entry, wheezing, or crackles 1
• Assess oxygen saturation via pulse oximetry immediately 2
• Provide rescue breathing or bag-mask ventilation if respiratory arrest is present 1

Circulation Evaluation

• Check for pulse presence and quality (carotid or femoral) 1, 2
• Assess blood pressure, heart rate, capillary refill time, and skin perfusion 1
• Establish large-bore intravenous access (two sites if possible) 1
• Begin fluid resuscitation with normal saline 0.9% or lactated Ringer's solution if hypotension is present 1
• Initiate cardiopulmonary resuscitation immediately if cardiac arrest is confirmed, with high-quality chest compressions at 100-120/minute and depth of 2-2.4 inches 1

Disability Assessment

• Rapidly assess mental status using AVPU scale (Alert, responds to Voice, responds to Pain, Unresponsive) 1
• Check pupil size, equality, and reactivity 2
• Assess for focal neurological deficits 1

Exposure

• Remove clothing to perform complete examination while preventing hypothermia 2
• Look for signs of trauma, bleeding, rashes, or other external findings 1, 2

Critical Actions During Initial Minutes

Simultaneous Team-Based Interventions

Call for Help and Activate Emergency Systems

• Do not delay emergency response system activation while performing initial interventions 1
• Note the exact time of emergency recognition 1
• Assign team roles if multiple providers are available 1, 2

Elevate Legs if Hypotensive

• Position patient supine with legs elevated to improve venous return if hypotension is present without contraindications 1

Remove Causative Agents

• Stop all potentially harmful exposures immediately (medications, allergens, toxins) 1

Diagnostic Work-Up (Performed Concurrently)

Essential Immediate Diagnostics

12-Lead Electrocardiogram

• Obtain within first few minutes to identify ST-elevation myocardial infarction, arrhythmias, or electrolyte abnormalities 1
• ECG is rarely normal in acute cardiovascular emergencies but rarely diagnostic alone 1

Point-of-Care Testing

• Bedside glucose measurement for altered mental status 2
• Bedside ultrasound for cardiac activity, pericardial effusion, pneumothorax, or abdominal free fluid if expertise available 1

Laboratory Studies

• Blood gas analysis, complete blood count, electrolytes, renal function, cardiac biomarkers, lactate 1
• Coagulation studies if bleeding or anticoagulation suspected 1

Chest Radiography

• Obtain after stabilization to assess for pulmonary edema, pneumothorax, pneumonia, or alternative causes of dyspnea 1
• Normal chest X-ray does not exclude acute pathology (20% of acute heart failure patients have normal films) 1

Condition-Specific Initial Management

Suspected Opioid Overdose

Respiratory Arrest with Pulse Present

• Maintain rescue breathing or bag-mask ventilation until spontaneous breathing returns 1
• Administer naloxone 0.4-2 mg IV/IM/intranasal in addition to standard BLS/ACLS care 1
• Continue ventilatory support as naloxone effect may be delayed 1

Cardiac Arrest

• Prioritize high-quality CPR (compressions plus ventilation) over naloxone administration 1
• Naloxone can be given alongside CPR but should not delay chest compressions 1

Suspected Anaphylaxis

Immediate Epinephrine Administration

• Administer epinephrine 50 mcg IV (0.5 mL of 1:10,000 solution) for adults immediately 1, 6, 7
• Repeat every few minutes as needed for persistent hypotension or bronchospasm 1, 6
• If IV access unavailable, give 0.3-0.5 mg IM (1:1000 solution) into anterolateral thigh 1, 6, 7
• Start continuous epinephrine infusion if multiple boluses required: 1 mg in 250 mL D5W at 1-4 mcg/min, titrate to effect 6

Aggressive Fluid Resuscitation

• Administer normal saline 0.9% or lactated Ringer's at 5-10 mL/kg in first 5 minutes 1, 6
• Up to 7 liters may be required in adults due to massive capillary leak 6

Secondary Medications

• Chlorphenamine 10 mg IV and hydrocortisone 200 mg IV after epinephrine 1, 6
• Treat persistent bronchospasm with IV salbutamol infusion or inhaled beta-agonists 1, 6

Hemorrhagic Shock

Permissive Hypotension Strategy

• Target systolic blood pressure 80-90 mmHg until hemorrhage control achieved in penetrating trauma 1
• Avoid aggressive fluid resuscitation before surgical control of bleeding 1

Vasopressor Support

• Consider norepinephrine infusion if life-threatening hypotension persists despite fluid resuscitation 1
• Use cautiously as early vasopressor use may be deleterious compared to volume resuscitation 1

Acute Heart Failure

Blood Pressure-Guided Therapy

• If systolic BP >110 mmHg: initiate vasodilators (nitroglycerin or nitroprusside) 1
• If systolic BP 90-110 mmHg: give loop diuretics (furosemide 40-80 mg IV) 1
• If systolic BP <90 mmHg: consider inotropic support and vasopressors 1

Oxygen and Ventilatory Support

• Provide supplemental oxygen to maintain SpO2 >90% 1
• Consider non-invasive positive pressure ventilation for respiratory distress 1

Common Pitfalls to Avoid

Do Not Delay Definitive Interventions

• Avoid prolonged scene time in pre-hospital setting; rapid transfer to appropriate facility is critical 1
• Do not wait for complete diagnostic work-up before initiating life-saving treatments 1, 2

Recognize Atypical Presentations

• Anaphylaxis may present without cutaneous signs in 28% of cases 6
• Bradycardia occurs in 10% of anaphylaxis cases, not just tachycardia 6
• Hypotension may be the sole feature in 10% of anaphylaxis during anesthesia 6

Avoid Equipment-Related Errors

• Verify endotracheal tube placement immediately after intubation 1
• Exclude equipment failure (misplaced tube, oxygen supply issues) before attributing symptoms to disease process 1, 6

Medication Administration Errors

• Do not inject epinephrine into buttocks (risk of gas gangrene), digits, hands, or feet (risk of tissue necrosis) 7
• Use anterolateral thigh (vastus lateralis) for IM epinephrine administration 7
• Avoid repeated injections at same site due to vasoconstriction-induced tissue necrosis 7

Premature Discharge

• Observe patients who respond to naloxone in healthcare setting until risk of recurrent toxicity is low 1
• Monitor anaphylaxis patients for biphasic reactions which can occur hours after initial resolution 1, 6