What is the approach to evaluating an unresponsive patient arriving via Emergency Medical Services (EMS) in the Emergency Department (ED)?

From the Guidelines

When evaluating an unresponsive patient arriving via EMS in the emergency department, I follow a systematic approach starting with the primary survey using the ABCDE method, as recommended by the 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care 1.

Primary Survey

First, I assess the airway for patency and protect the cervical spine if trauma is suspected. I check breathing by observing chest rise, listening for breath sounds, and measuring oxygen saturation, providing supplemental oxygen or intubation if needed. For circulation, I evaluate pulses, blood pressure, capillary refill, and establish IV access for fluid resuscitation if signs of shock are present.

Secondary Survey

I perform a rapid neurological assessment using the Glasgow Coma Scale, check pupillary responses, and assess for lateralizing signs. I fully expose the patient to look for injuries, rashes, or other physical findings while maintaining temperature control.

History and Diagnostic Tests

Simultaneously, I obtain a focused history from EMS or family using the SAMPLE approach (Signs/Symptoms, Allergies, Medications, Past medical history, Last meal, Events preceding). Critical diagnostic tests include point-of-care glucose, ECG, portable chest X-ray, and laboratory studies (CBC, electrolytes, renal function, toxicology screen, arterial blood gas).

Differential Diagnosis

I consider common causes of unresponsiveness using the mnemonic AEIOU-TIPS: Alcohol/drugs, Epilepsy/seizures, Insulin (hypoglycemia), Overdose, Uremia, Trauma, Infection, Psychiatric, Stroke/shock, as suggested by the 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care 1.

Treatment

This systematic approach ensures no critical conditions are missed while rapidly identifying and treating life-threatening causes of unresponsiveness, and is supported by the 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations 1. Additionally, the implementation and integration of prehospital ECGs into systems of care for acute coronary syndrome, as described in the 2008 scientific statement from the American Heart Association, can aid in the diagnosis and treatment of cardiac-related causes of unresponsiveness 1.

From the Research

Initial Assessment of Unresponsive Patient

When an unresponsive patient arrives in the Emergency Department (ED) via EMS, the initial assessment is crucial in identifying life-threatening conditions. The ABCDE approach is a systematic method used to evaluate the patient's airway, breathing, circulation, disability, and exposure 2, 3.

• Airway: The first step is to assess the patient's airway, ensuring it is patent and protected. This involves checking for any obstruction, trauma, or other conditions that may compromise the airway 4, 5.
• Breathing: Next, evaluate the patient's breathing, looking for signs of respiratory distress, such as tachypnea, bradypnea, or abnormal breath sounds 2, 3.
• Circulation: Assess the patient's circulation, checking for signs of shock, such as tachycardia, hypotension, or decreased peripheral pulses 2, 3.
• Disability: Evaluate the patient's neurological status, checking for signs of altered mental status, such as confusion, disorientation, or decreased level of consciousness 2, 3.
• Exposure: Finally, expose the patient to assess for any other injuries or conditions that may have been missed during the initial assessment 2, 3.

Airway Management

Airway management is a critical component of the initial assessment, and endotracheal intubation (ETI) is often necessary in unresponsive patients. The decision to perform ETI should be based on the patient's clinical condition and the availability of skilled personnel 5, 6.

• Preoxygenation and Apneic Oxygenation: Preoxygenation and apneic oxygenation are recommended to reduce the risk of desaturation and patient decompensation 5.
• Induction and Neuromuscular Blocking Medications: Induction and neuromuscular blocking medications should be tailored to the clinical scenario 5.
• Video Laryngoscopy: Video laryngoscopy is superior to direct laryngoscopy among novice users, while both techniques are reasonable among more experienced clinicians 5.
• Confirmation of Correct Placement: Point-of-care ultrasound is helpful for confirming correct placement and depth of the endotracheal tube 5.

Checklist for Evaluating Unresponsive Patient

The following checklist can be used to evaluate an unresponsive patient in the ED:

• Assess airway, breathing, circulation, disability, and exposure using the ABCDE approach
• Check vital signs and record using a track and trigger tool
• Evaluate the need for endotracheal intubation and perform if necessary
• Use preoxygenation and apneic oxygenation to reduce the risk of desaturation
• Tailor induction and neuromuscular blocking medications to the clinical scenario
• Use video laryngoscopy or direct laryngoscopy for ETI
• Confirm correct placement of the endotracheal tube using point-of-care ultrasound
• Continuously monitor the patient's condition and adjust treatment as needed 2, 3, 4, 5, 6.