What are the initial stabilization steps for a patient at a medical scene with potential trauma, cardiac arrest, or altered mental status?

Paramedic Stabilization at a Medical Scene

Immediately assess responsiveness by shaking the patient's shoulders and shouting "Are you all right?" while simultaneously activating emergency services and retrieving an AED. 1, 2

Initial Assessment (Primary Survey)

Scene Safety and Responsiveness Check

• Ensure scene safety before approaching to prevent harm to yourself and others 3
• Check responsiveness by gently shaking shoulders and shouting loudly 1
• Shout for nearby help immediately and activate emergency response system 1
• Send someone to retrieve AED and emergency equipment or get it yourself if alone 1

Airway and Breathing Assessment

• Open the airway using head tilt-chin lift maneuver: place one hand on forehead tilting head back while lifting chin with fingers of other hand 1, 2
• Loosen tight clothing around neck and remove any obvious airway obstruction 1
• Remove loose dentures but leave well-fitting dentures in place 1
• Assess breathing for no more than 10 seconds by simultaneously looking for chest movements, listening at mouth for breath sounds, and feeling for air with your cheek 1, 2, 3

Circulation Assessment

• Check carotid pulse for no more than 10 seconds while assessing for any signs of movement, swallowing, or breathing (more than occasional gasps) 1, 2

Action Based on Assessment Findings

If Patient is Responsive

• Leave patient in position found unless in further danger 1
• Check for injuries and reassess responsiveness at intervals 1
• Obtain additional help if needed 1

If Patient is Breathing with Pulse Present

• Place in recovery position (lateral recumbent with arm nearest you at right angle, far knee flexed) to prevent aspiration and maintain airway patency 1, 2, 3
• Monitor continuously until emergency responders arrive 1
• Reposition supine immediately if respiratory status deteriorates 2

If Patient Has Pulse But No Breathing

• Provide rescue breathing at 10 breaths per minute (one breath every 6 seconds) 1, 2
• Each breath should take 1.5-2 seconds and achieve visible chest rise of 400-600 ml tidal volume 1, 2
• Maintain head tilt-chin lift continuously throughout rescue breathing 2
• Pinch nose closed with index finger and thumb while delivering breaths 1
• Reassess pulse every 2 minutes; if no pulse develops, immediately start CPR 1, 2
• If possible opioid overdose, administer naloxone if available per protocol 1

If Patient Has No Pulse (Cardiac Arrest)

• Begin high-quality CPR immediately with chest compressions as the most critical intervention 1, 2

Chest Compression Technique:

• Position hands correctly on lower half of sternum: locate where ribs join sternum, place middle finger at this point with index finger on sternum, then slide heel of other hand down to meet index finger 1, 2
• Interlock fingers of both hands and lift to ensure pressure not applied over ribs 1
• Position yourself vertically above patient's chest with arms straight 1
• Push hard and fast: compress at least 5 cm depth (4-5 cm acceptable range) 1, 2, 4
• Deliver compressions at 100-120 per minute (slightly less than 2 compressions per second) 1, 4
• Allow complete chest recoil after each compression 1, 4
• Minimize interruptions in compressions to maintain perfusion 1, 2

Ventilation During CPR:

• Deliver compressions and breaths in 30:2 ratio if alone 1, 2
• After 15 compressions, tilt head, lift chin, and give 2 effective breaths, then immediately return hands to sternum 1
• Each breath should achieve visible chest rise 1
• Avoid excessive ventilation which increases intrathoracic pressure and impairs venous return 2

Defibrillation:

• Apply AED as soon as available and follow prompts for rhythm analysis 1, 2
• If shockable rhythm detected, deliver one shock then immediately resume CPR for 2 minutes 1
• If non-shockable rhythm, immediately resume CPR for 2 minutes 1

Advanced Interventions (if trained/equipped):

• Establish IV/IO access once available 1
• Administer epinephrine 1 mg IV/IO every 3-5 minutes once vascular access established 1, 2
• Change compressor every 2 minutes or sooner if fatigued to maintain quality 1

Critical Pitfalls to Avoid

• Do not delay CPR to assess for injuries or obtain history—resuscitation takes absolute priority 2
• Do not spend more than 10 seconds checking pulse or breathing before initiating interventions 1, 2
• Do not interrupt chest compressions except for rhythm analysis, defibrillation, or pulse checks every 2 minutes 1
• Do not inflate too quickly during rescue breathing—this increases resistance and causes gastric insufflation 1
• Do not apply pressure over ribs, upper abdomen, or bottom tip of sternum during compressions 1

Special Considerations for Trauma

• If trauma suspected, maintain spinal precautions while opening airway, but do not delay life-saving interventions 2
• Assess for external hemorrhage and apply direct pressure to control bleeding if present 2

Ongoing Management

• Continue CPR until: patient shows signs of life, advanced life support providers take over, you are physically unable to continue, or scene becomes unsafe 1, 4
• Reassess frequently for any changes in patient status 1
• Prepare for rapid transport once advanced care arrives 1