What are the management guidelines for top medical emergencies such as cardiac arrest, severe asthma exacerbation, status epilepticus, and severe trauma in the emergency room?

Top Medical Emergencies and Their Management in the Emergency Room

Severe Asthma Exacerbation

All patients with severe asthma exacerbation should receive immediate high-flow oxygen (40-60%) to maintain SaO₂ >92%, nebulized beta-agonists (salbutamol 5 mg), and systemic corticosteroids (prednisolone 30-60 mg orally or hydrocortisone 200 mg IV) within minutes of arrival. 1, 2

Initial Recognition and Triage

• Severe exacerbation features: inability to speak in complete sentences, respiratory rate >25 breaths/min, heart rate >110 beats/min, and peak expiratory flow (PEF) <50% of predicted or personal best 1, 3
• Life-threatening features requiring immediate ICU consideration: PEF <33% predicted, silent chest on auscultation, cyanosis or weak respiratory effort, altered mental status or confusion, and PaCO₂ ≥42 mmHg 1, 2
• Risk factors for asthma-related death to identify: previous intubation or ICU admission, ≥2 hospitalizations in past year, ≥3 ED visits in past year, using >2 canisters of short-acting beta-agonist per month 3

First-Line Treatment Protocol

• Oxygen therapy: Administer high-flow oxygen (40-60%) via face mask immediately to maintain SaO₂ >92% (>95% in pregnant patients or those with cardiac disease), even in patients with normal initial oxygenation 1, 3
• Bronchodilators: Nebulized salbutamol 5 mg via oxygen-driven nebulizer as first-line treatment; alternative is terbutaline 10 mg nebulized or 10-20 puffs of salbutamol via metered-dose inhaler with spacer 1, 2, 3
• Corticosteroids: Prednisolone 30-60 mg orally (or hydrocortisone 200 mg IV if unable to take oral medication) for adults; prednisolone 1-2 mg/kg body weight orally (maximum 40 mg) for children 1, 2, 3

Reassessment and Escalation

• Measure PEF and reassess clinical status at 15-30 minutes after initial treatment 1, 2
• If no improvement after initial treatment: Continue oxygen and corticosteroids, increase beta-agonist frequency to every 15-30 minutes, and add ipratropium 0.5 mg nebulized 2, 3
• Consider IV magnesium sulfate 2 g over 20 minutes for life-threatening exacerbations or severe exacerbations persisting after 1 hour of intensive treatment 1

Critical Pitfalls to Avoid

• Never administer sedatives of any kind during an acute asthma exacerbation, as this can precipitate respiratory failure 1, 2
• Do not underestimate severity based on initial presentation, as patients can deteriorate rapidly to cardiac arrest; asphyxia is the most common cause of death 1, 3
• Avoid bolus aminophylline in patients already taking oral theophyllines 2

Intubation Considerations

• Signs requiring immediate intubation consideration: inability to speak, worsening confusion or altered mental status, intercostal retraction with worsening fatigue, rising PaCO₂ ≥42 mmHg, and exhaustion despite maximal therapy 1, 2
• When intubation becomes necessary, it should not be attempted until the most expert available physician (ideally an anesthetist) is present 1, 3

Monitoring Requirements

• Continuous pulse oximetry to maintain SaO₂ >92% 1, 2
• PEF measurement before and after each nebulization 1, 2
• Respiratory rate and heart rate every 15-30 minutes initially 1
• Arterial blood gas if PEF <25% predicted, severe distress, or suspected hypoventilation 1

Admission Criteria

• Admit to hospital if: life-threatening characteristics present, severe exacerbation persists after initial treatment, PEF <33% after treatment, recent nocturnal symptoms or previous severe attacks, or inability to assess own condition 1

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Cardiac Arrest in Special Situations

Cardiac arrest management must be modified based on the underlying cause, with specific interventions for asthma-related arrest, trauma, pregnancy, pulmonary embolism, and other special circumstances beyond standard BLS and ACLS protocols. 3

Cardiac Arrest Associated with Asthma

• Pathophysiology: The most common cause of death is asphyxia from severe bronchoconstriction, airway inflammation, and mucous plugging; cardiac causes are less common 3
• During resuscitation: Provide high-quality CPR while aggressively treating the underlying asthma with oxygen, nebulized beta-agonists, and corticosteroids 3
• Key consideration: Severe hyperinflation can cause hypotension due to decreased venous return; brief disconnection from ventilator may be necessary if auto-PEEP suspected 3

Special Situations Requiring Modified Protocols

The American Heart Association guidelines address 15 specific cardiac arrest situations requiring special treatments: 3

• Internal/metabolic conditions: asthma, anaphylaxis, pregnancy, morbid obesity, pulmonary embolism, electrolyte imbalance 3
• Environmental circumstances: toxic ingestion, trauma, accidental hypothermia, avalanche, drowning, electric shock/lightning strikes 3
• Cardiac-specific situations: percutaneous coronary intervention, cardiac tamponade, cardiac surgery 3

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Status Epilepticus

Status epilepticus requires immediate benzodiazepine administration followed by second-line antiepileptic drugs if seizures persist, with airway protection and rapid identification of reversible causes being paramount.

Post-Cardiac Arrest Seizures

• Seizures occurring >72 hours post-arrest may not necessarily indicate 100% poor neurological outcome, particularly in patients treated with therapeutic hypothermia 4
• Therapeutic hypothermia (33°C for 24 hours) may alter traditional prognostic indicators after cardiac arrest, requiring re-examination of previously established poor outcome predictors 4

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Severe Trauma

Multiple trauma patients require immediate classification into three severity classes to determine the appropriate balance between life-saving interventions and diagnostic imaging.

Classification System for Trauma Management

Class 1 (Severely injured with serious distress): 5

• Immediate life-saving treatments required: tracheal intubation and mechanical ventilation for severe brain trauma or acute respiratory failure, chest tube placement for massive pleural effusion, emergency surgery for hemostasis 5
• Limited imaging only: chest x-ray, abdominal ultrasonography, and echocardiography if needed 5

Class 2 (Seriously injured but stabilized with intensive care): 5

• Specific imaging to detect potentially lethal injuries: abdominal ultrasound, chest x-ray (4 views), angiography for embolization, brain CT scan 5
• Treatment guided by imaging findings while maintaining hemodynamic stability with massive vascular loading 5

Class 3 (Stabilized by field medical management): 5

• Total body CT scan first to obtain quick and precise diagnosis of all injuries 5
• Then organize specific imaging procedures or specific surgery based on CT findings 5

Essential Infrastructure Requirements

• Trained medical and paramedical staff including emergency physicians and anesthesiologists both in-hospital and in the field 5
• Efficient medical dispatching to transport patients to hospitals capable of immediate comprehensive management 5
• Availability of surgeons from multiple specialties and radiologists for immediate consultation 5
• Goal is not fastest transport to nearest center, but logical strategy for quickest discharge with least sequelae 5