What are the initial steps in emergency management for a patient with severe injuries or illnesses, such as trauma, stroke, or myocardial infarction, with unstable vital signs, including interventions like oxygen administration, cardiopulmonary resuscitation (CPR), automated external defibrillators (AEDs), and medication like epinephrine?

Emergency Management of Severe Injuries or Illnesses with Unstable Vital Signs

For any patient with severe injury or illness and unstable vital signs, immediately verify scene safety, check responsiveness, activate emergency response, and begin high-quality CPR with chest compressions at 100-120/min and depth of at least 5 cm if the patient is pulseless, while simultaneously preparing for early defibrillation. 1, 2

Initial Assessment and Scene Safety

• Verify scene safety first before approaching any patient to prevent becoming a second victim—this is the absolute first step in any emergency 1, 2
• Check for responsiveness by shouting and tapping the victim 1, 2
• Immediately activate the emergency response system (call 9-1-1 or equivalent) and retrieve an AED, or send someone to do so if multiple rescuers are present 1, 2
• Simultaneously assess breathing and pulse within 10 seconds—look for no breathing or only gasping while checking for a pulse 1, 2

Critical pitfall: Do not spend more than 10 seconds checking for a pulse; if uncertain, immediately begin CPR as the risk of providing unnecessary CPR is far less than withholding it when needed 1, 3

Immediate CPR for Pulseless Patients

Chest Compressions (Priority #1)

• Begin chest compressions immediately if no pulse is detected within 10 seconds—compressions take absolute priority over airway management 1, 2, 3
• Push hard and fast: compress at least 5 cm (2 inches) deep at a rate of 100-120 compressions per minute 1, 2, 3
• Allow complete chest recoil between compressions—incomplete recoil prevents cardiac refilling and is a critical error 1, 2, 3
• Minimize interruptions in compressions; any pause reduces survival 1, 2, 3
• Change compressors every 2 minutes to prevent fatigue and maintain compression quality 1, 4

Compression-to-Ventilation Ratio

• Use 30 compressions followed by 2 breaths for single rescuers 1, 3
• For pediatric patients with 2 or more rescuers, use 15 compressions to 2 breaths 1, 2
• Untrained rescuers should provide compression-only CPR rather than no CPR 1, 3

Critical pitfall: Do not lean on the chest between compressions—this prevents adequate cardiac refilling and reduces CPR effectiveness 2, 3

Early Defibrillation

• Use the AED as soon as it becomes available—do not delay CPR to retrieve it, but apply immediately once present 1, 2, 3
• Check rhythm to determine if shockable (ventricular fibrillation or pulseless ventricular tachycardia) 1, 2
• If shockable rhythm: deliver one shock immediately, then resume CPR for 2 minutes before reassessing rhythm 1, 2, 3
• If non-shockable rhythm: resume CPR immediately for 2 minutes before reassessing 1, 3
• Use biphasic 120-200 joules for initial shock (or manufacturer recommendation); if unknown, use maximum available 1, 4

Advanced Life Support Interventions

Medication Administration

• Establish IV or intraosseous (IO) access as soon as possible 1, 3, 4
• Administer epinephrine 1 mg IV/IO every 3-5 minutes for all cardiac arrest rhythms 1, 2, 3, 5
• For refractory ventricular fibrillation/pulseless ventricular tachycardia: give amiodarone 300 mg IV bolus (first dose), then 150 mg (second dose) 1, 4
• Alternative to amiodarone: lidocaine 1-1.5 mg/kg IV/IO (first dose), then 0.5-0.75 mg/kg (second dose) 1

Airway Management

• Once advanced airway is placed, provide ventilation at 1 breath every 6 seconds (10 breaths/minute) with continuous chest compressions 3, 4
• Avoid excessive ventilation—this increases intrathoracic pressure and reduces venous return 1

Critical pitfall: Do not interrupt compressions for prolonged periods to manage the airway; compressions are more important than advanced airway placement in the first minutes of resuscitation 1, 2

Oxygen Administration for Non-Arrest Patients

Stroke Patients

• Administer supplemental oxygen to hypoxemic stroke patients (oxygen saturation <94%) 1
• Do not initiate blood pressure intervention in the prehospital environment unless systolic BP <90 mmHg 1
• For stroke patients eligible for fibrinolytic therapy with BP >185/110 mmHg, consider labetalol 10-20 mg IV over 1-2 minutes or nicardipine IV 5 mg/hr titrated up 1

Acute Coronary Syndrome Patients

• Check oxygen saturation and administer oxygen at 4 L/min if saturation <94%, titrating as needed 1
• Administer aspirin 160-325 mg immediately 1
• Give nitroglycerin sublingual or spray for chest discomfort 1
• Administer morphine IV if discomfort not relieved by nitroglycerin 1

Patients with Pulse but No Normal Breathing

• Provide rescue breathing at 1 breath every 6 seconds (10 breaths/minute) for adults 1, 3
• For pediatric patients: provide 1 breath every 2-3 seconds (20-30 breaths/minute) 1
• Check pulse every 2 minutes; if no pulse develops, immediately start CPR 1, 3
• For suspected opioid overdose, administer naloxone if available while continuing rescue breathing 1, 2, 3

Rhythm Assessment and Ongoing Management

• Check rhythm every 2 minutes during CPR 1, 3, 4
• Continue CPR until advanced life support providers take over or the patient starts to move 1, 2
• Monitor CPR quality continuously: adequate depth, rate, recoil, and minimal interruptions 1, 2

Special Considerations for Trauma Patients

Important nuance: While the standard cardiac arrest sequence prioritizes circulation (CAB approach), trauma patients with active hemorrhage may benefit from prioritizing circulation over airway management, as early intubation can cause post-intubation hypotension and increased mortality 6. However, patients with critical hypoxia or airway injury still require immediate airway management 6.

Post-Resuscitation Care (After Return of Spontaneous Circulation)

• Maintain mean arterial pressure >80 mmHg or systolic BP >100 mmHg 4
• Use norepinephrine as preferred vasopressor if needed 4
• Avoid hyperthermia; consider targeted temperature management 32-34°C for 24 hours in comatose survivors 4
• Correct electrolyte abnormalities aggressively (potassium, magnesium, calcium) 4
• Maintain normoglycemia 4

Critical pitfall: Do not prognosticate neurological outcome before 72 hours post-resuscitation, especially with therapeutic hypothermia—use multimodal assessment after this period 4