What is the initial management for a patient involved in an accident emergency?

Initial Management of Accident Emergency Patients

The first priority in accident emergency management is to ensure scene safety, then immediately assess and address life-threatening conditions using the ABCDE approach (Airway, Breathing, Circulation, Disability, Exposure), with immediate activation of emergency medical services (EMS) by calling 9-1-1 for any unresponsive patient or signs of severe injury. 1

Scene Safety and Initial Response

• Ensure the scene is safe before approaching the victim—if the area is unsafe, move the patient only if absolutely necessary to reach a safe location 1
• Check for responsiveness by tapping the victim's shoulder and shouting "Are you all right?" 1
• If the patient is unresponsive with no breathing or only gasping, immediately activate EMS (call 9-1-1) before beginning resuscitation 1

Critical Decision: When to Call for Help vs. Provide Immediate Care

• If you are alone with a victim who has imminent life-threatening conditions (airway obstruction, severe bleeding), provide basic care first (open airway, apply pressure to bleeding) before leaving to call for help 1
• If two or more rescuers are present, one should begin immediate care while the second activates EMS and retrieves an AED 1

Primary Survey: ABCDE Approach

A - Airway Assessment and Management

• Open the airway in unresponsive patients—this is the most critical step without which resuscitation is hopeless 2, 3
• For patients with suspected spinal injury (based on mechanism such as falls >20 feet, high-speed motor vehicle crashes, diving injuries), do not move the patient unless the airway is blocked or the area is unsafe 1, 4
• If the patient is unresponsive but breathing normally, place in the lateral recovery position (side-lying with head on extended arm, both legs bent) to maintain airway patency—unless spinal injury is suspected 1

B - Breathing Assessment

• Check for no breathing or only gasping—gasping does not equal adequate breathing and should be treated as cardiac arrest 1
• Avoid hyperventilation in trauma patients, as this increases mortality through cerebral vasoconstriction and decreased venous return 1, 4
• Maintain normoventilation unless there are signs of imminent cerebral herniation 1

C - Circulation and Hemorrhage Control

For patients with exsanguinating hemorrhage, emerging evidence supports prioritizing circulation control BEFORE advanced airway management to avoid post-intubation hypotension and improve survival. 5

Immediate Hemorrhage Control:

• Apply direct pressure to all external bleeding sites immediately 4
• For severe extremity bleeding (mangled limbs, traumatic amputations, penetrating/blast injuries), apply a tourniquet immediately—this is simple, efficient, and life-saving 1, 4
• Tourniquets should remain in place until surgical control is achieved, ideally within 2 hours (though survival has been documented up to 6 hours) 1

Assessment of Shock Severity:

• Use the ATLS classification to grade blood loss based on vital signs 1, 4:

  • Class I: <15% blood loss, pulse <100, normal BP
  • Class II: 15-30% loss, pulse 100-120, normal BP
  • Class III: 30-40% loss, pulse 120-140, decreased BP, anxious/confused
  • Class IV: >40% loss, pulse >140, severely decreased BP, confused/lethargic

• Class III and IV hemorrhage require immediate surgical bleeding control 4

Shock Positioning:

• Place responsive patients showing signs of shock in the supine position 1
• If no trauma is suspected (simple fainting, non-traumatic bleeding), consider raising the feet 6-12 inches (30-60°) while awaiting EMS—this may temporarily improve cardiac output for up to 7 minutes 1
• Never raise the feet if movement causes pain 1

D - Disability (Neurological Status)

• Assess mental status using the ATLS classification: alert, anxious, confused, or lethargic 1
• Altered mental status indicates at least Class III hemorrhage (30-40% blood loss) 1

E - Exposure

• Remove wet clothing to prevent heat loss in trauma patients 1
• Insulate or shield the victim from environmental extremes 1

CPR for Cardiac Arrest

If the patient is unresponsive with no breathing or only gasping:

• Begin chest compressions immediately at a rate of at least 100/min with depth of at least 2 inches (5 cm) 1
• Allow complete chest recoil after each compression 1
• Minimize interruptions in compressions 1
• Provide cycles of 30 compressions to 2 breaths 1
• Healthcare providers may check for a pulse but should take no more than 10 seconds—if no definite pulse is felt, start compressions 1
• Use an AED as soon as available, following device prompts, and resume CPR immediately after any shock 1

Special Circumstances

Drowning Victims

• Remove from water by the fastest means available and begin resuscitation immediately 1
• Do not perform abdominal thrusts or attempt to clear water from the airway—this delays CPR and can cause harm 1
• Spinal immobilization is only needed if there are obvious signs of injury, diving into shallow water, or alcohol intoxication 1

Hypothermia

• Do not delay CPR to check temperature or wait for rewarming 1
• Continue resuscitation efforts until the patient is evaluated by advanced care providers 1
• Remove wet clothes and provide passive warming 1

Choking (Foreign Body Airway Obstruction)

• Ask "Are you choking?"—if the victim nods yes without speaking, this confirms severe airway obstruction 1
• Intervene immediately for signs of severe obstruction: silent cough, cyanosis, inability to speak or breathe 1
• The universal choking sign is clutching the neck 1

Critical Pitfalls to Avoid

• Never delay tourniquet application for severe extremity bleeding—waiting increases blood loss and mortality 4
• Never hyperventilate trauma patients—this significantly increases mortality 1, 4
• Never move a patient with suspected spinal injury unless absolutely necessary for airway management or scene safety 1, 4
• Never delay calling EMS beyond providing immediate life-saving interventions (opening airway, controlling severe bleeding) 1
• Never confuse gasping with normal breathing—gasping indicates cardiac arrest and requires immediate CPR 1