What are the initial steps and treatments for various patient types during emergency RMO (Resident Medical Officer) recall, considering their airway, breathing, and circulation (ABCs), past medical history, and current medications?

Emergency RMO Recall: Patient Types and Initial Treatment Protocol

When responding to an emergency RMO recall, immediately assess and stabilize the patient using the ABCDE approach (Airway, Breathing, Circulation, Disability, Exposure) in strict sequential order, as this systematic framework enables identification and treatment of life-threatening conditions by priority. 1, 2

Initial Scene Assessment and Safety

• Ensure your own safety and the patient's safety before approaching by checking for environmental hazards such as electrical sources, traffic, or structural dangers 2
• Check responsiveness by gently shaking the patient's shoulders while asking loudly "Are you all right?" to determine consciousness level 2
• Designate a timekeeper to call out times at 1-minute intervals for critical interventions 3
• Call for help immediately and note the time 3

A - Airway Management

Open and secure the airway as the absolute first priority, as airway compromise leads to rapid deterioration and death. 1, 2

• Use head tilt-chin lift maneuver: place one hand on forehead and gently tilt head back while lifting chin with fingertips under the bony part of chin 3, 2
• Avoid head tilt if trauma to neck is suspected—instead use jaw thrust without head extension to minimize cervical spine movement 3, 2
• Remove any visible obstruction from mouth including dislodged dentures, but leave well-fitting dentures in place 3, 2
• If the patient has difficulty breathing but is awake and alert, allow them to assume the most comfortable position for breathing (usually sitting up) 1
• For patients with decreased alertness of nontraumatic cause who are breathing normally, position in recovery (side-lying) position 1
• If trauma is suspected to neck, back, hip, or pelvis, leave patient in position found unless airway is compromised or area is unsafe 1

B - Breathing Assessment and Management

Look, listen, and feel for breathing for exactly 10 seconds—no more, no less—as delays worsen outcomes. 3, 2

• Look for chest movements, listen at the victim's mouth for breath sounds, and feel for air on your cheek 3, 2
• Occasional gasps do not count as normal breathing 2
• Administer 100% oxygen immediately to all critically ill patients 3, 1
• Apply supplemental oxygen to maintain appropriate saturation 1
• Monitor respiratory rate continuously as this is a critical indicator of respiratory status 4

If Patient is NOT Breathing:

• Give 2 effective rescue breaths, each making the chest rise and fall 3
• Ensure head tilt and chin lift, pinch soft part of nose closed 3
• Take a breath and place lips around mouth with good seal 3
• Blow steadily for 1.5-2 seconds, watching for chest rise (400-600 mL air in adults) 3
• If difficulty achieving effective breath: recheck mouth for obstruction, recheck head tilt/chin lift, make up to 5 attempts total to achieve 2 effective breaths 3
• Even if unsuccessful, move on to circulation assessment 3

For Bronchospasm:

• Administer salbutamol via nebulizer or metered-dose inhaler if suitable breathing-system connector available 3, 5
• Consider ipratropium bromide inhalation solution mixed with albuterol in nebulizer if used within one hour 6
• Consider intravenous aminophylline or magnesium sulphate for persistent bronchospasm 3

C - Circulation Assessment and Management

Assess for signs of circulation by checking carotid pulse at a single site while simultaneously looking for breathing—take no more than 10 seconds total. 2

• Look for any movement including swallowing or breathing (more than occasional gasp) 3
• Check carotid pulse at ONE site only—do not check bilateral or multiple sites as this wastes critical time 2
• If no pulse is definitively palpated within 10 seconds or you are uncertain, start chest compressions immediately 2

If NO Pulse or Signs of Circulation:

• Locate lower half of sternum using index and middle fingers to identify lower rib margin 3
• Place heel of hand on middle of lower half of sternum with other hand on top 3
• Interlock fingers and lift to ensure pressure not applied over ribs 3
• Position vertically above chest with arms straight, press down 4-5 cm 3
• If pregnant or suspected pregnancy, manually displace uterus or use lateral tilt 3
• Consider perimortem cesarean delivery (resuscitative hysterotomy) if no pulse at 4 minutes in pregnant patient 3

For Hypotension/Shock:

• Apply tourniquets or local compression to stop life-threatening bleeding 1
• Initiate IV fluid resuscitation with normal saline 1-2 L at rate of 5-10 mL/kg in first 5 minutes 3
• Administer crystalloids or colloids in boluses of 20 mL/kg followed by slow infusion 3
• Consider intraosseous line if needed for large-bore IV access 3
• Calculate shock index (heart rate/systolic BP)—shock index ≥0.9-1.0 indicates significant blood loss 1
• Target mean arterial pressure ≥65 mmHg, urine output ≥0.5 mL/kg/h, and lactate normalization 3

For Anaphylaxis (if suspected):

Epinephrine is the first-line treatment and must be delivered immediately—do not delay. 3

• Administer epinephrine 0.2-0.5 mg (1 mg/mL) intramuscularly into lateral thigh muscle 3
• Initial dose of 50 μg (0.5 mL of 1:10,000 solution) IV is appropriate for adults if IV access established 3
• Repeat every 5-15 minutes as needed 3
• Several doses may be required for severe hypotension or bronchospasm 3
• Consider starting IV infusion of epinephrine if several doses required (short half-life) 3
• Administer diphenhydramine 50 mg IV plus ranitidine 50 mg IV 3
• Administer hydrocortisone 200 mg IV (adult dose) or equivalent dose to 1-2 mg/kg IV (methyl)prednisolone every 6 hours 3
• If bradycardia: atropine 600 μg IV 3
• If hypotension persists: dopamine 400 mg in 500 mL at rate 2-20 μg/kg/min OR vasopressin 25 U in 250 mL (0.1 U/mL), dose 0.01-0.04 U/min 3
• If patient on beta-blockers: glucagon 1-5 mg IV infusion over 5 minutes 3

For Infusion Reactions (Cytokine-Release/Hypersensitivity):

• Stop the infusion immediately 3
• Maintain IV access 3
• Grade 1: Slow rate of infusion 3
• Grade 2: Slow rate or short-term cessation, treat with H1/H2 antagonists and corticosteroids, restart at 50% rate 3
• Grade 3/4: Stop infusion, administer H1/H2 antagonists and corticosteroids, rechallenge discouraged 3

D - Disability (Neurological Assessment)

Rapidly assess neurological status using Glasgow Coma Scale and check blood glucose immediately to rule out hypoglycemia. 1

• Check blood glucose level as hypoglycemia is a rapidly reversible cause of altered mental status 1
• Control seizures if present 1
• Monitor for signs of cerebral herniation 1

E - Exposure

Completely undress the patient to facilitate thorough examination, but prevent hypothermia. 1

• Remove all clothing including wet clothing to prevent hypothermia 1
• Implement warming measures as needed 1
• Perform point-of-care ultrasonography (POCUS) including FAST for patients with thoracoabdominal injuries 1

Monitoring and Documentation

• Monitor cardiac rhythm via electrocardiogram when appropriate 1
• Measure pulse rate, respiratory rate, blood pressure, and continuous pulse oximetry 4
• Continue vital signs monitoring until patient is stable 4
• Monitor for 24 hours if severe reaction occurred 3
• Take blood samples for Mast Cell Tryptase if anaphylaxis suspected: initial sample during resuscitation, second at 1-2 hours, third at 24 hours 3

Common Pitfalls to Avoid

• Never spend more than 10 seconds on pulse check—if uncertain, start compressions immediately 2
• Never check bilateral carotid pulses simultaneously or sequentially—this wastes precious time and is not supported by guidelines 2
• Never delay moving to next assessment step if initial maneuvers unsuccessful—move on to circulation rather than persisting with unsuccessful breaths 2
• Never perform violent shaking during responsiveness checks—use gentle shoulder shaking with verbal stimulation to avoid head or cervical spine injuries 2
• Never rely solely on pulse oximeter for monitoring ventilation 4
• Do not delay resuscitation to take blood samples 3