What is the initial emergency management for an adult presenting with shock, acute coronary syndrome, stroke, severe dyspnea, unconsciousness, or status epilepticus?

Primary Emergency Management of Critical Medical Conditions

For any unresponsive patient, immediately ensure scene safety, check for response, assess breathing (looking for absent or only gasping respirations), activate emergency response, and begin high-quality CPR if no pulse is detected within 10 seconds. 1

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Unconscious Patient - Initial Assessment

The first priority is determining if the patient is in cardiac arrest versus another cause of unconsciousness.

Immediate Actions:

• Tap the victim's shoulder and shout "Are you all right?" to assess responsiveness 1
• Simultaneously check for absent or abnormal breathing (only gasping qualifies as absent breathing) 1
• If unresponsive with no breathing or only gasping, assume cardiac arrest and immediately activate emergency response 1
• Check for definite pulse within 10 seconds maximum - if no pulse detected, begin CPR immediately 1

If Pulse Present but Unconscious:

• Provide rescue breathing at 1 breath every 5-6 seconds (10-12 breaths/minute) 1
• Recheck pulse every 2 minutes 1
• Administer supplemental oxygen to maintain saturation ≥94% 1
• Check blood glucose immediately - hypoglycemia can mimic other emergencies 1, 2
• Establish IV access and obtain baseline labs 1

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Shock - Immediate Stabilization

Shock requires immediate recognition and aggressive hemodynamic support to prevent multiorgan failure and death.

Initial Management:

• Ensure airway patency and provide high-flow oxygen 1
• Establish large-bore IV access (two lines preferred) 1
• Begin rapid fluid resuscitation for hypovolemic/distributive shock 3
• Obtain baseline vital signs, ECG, and laboratory studies including lactate 1

Cardiogenic Shock Specific:

• Inotropes and vasopressors are first-line pharmacological therapy for hemodynamic instability 3
• Early coronary revascularization is cornerstone therapy when ACS is the cause - this reduces mortality 3, 4
• Perform cardiac catheterization urgently 3, 4
• Monitor for multiorgan failure - cardiogenic shock has 59.4% in-hospital mortality 4

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Acute Coronary Syndrome/Ischemic Heart Disease

Obtain 12-lead ECG within 10 minutes of presentation to distinguish STEMI from NSTE-ACS - this determines the entire treatment pathway. 5

STEMI Management:

• Primary PCI within 120 minutes is the gold standard - reduces mortality from 9% to 7% 5
• If PCI unavailable within 120 minutes, administer fibrinolytic therapy (alteplase, reteplase, or tenecteplase at full dose for age <75 years, half dose for ≥75 years) 5
• Transfer to PCI-capable facility within 24 hours after fibrinolysis 5

NSTE-ACS Management:

• Measure high-sensitivity troponin - this is the preferred diagnostic test 5
• For high-risk patients, perform invasive coronary angiography within 24-48 hours - reduces mortality from 6.5% to 4.9% 5
• Administer aggressive medical therapy: antiplatelet agents, anticoagulation, anti-ischemic medications, and statins 6

Common Pitfall:

• Approximately 40% of men and 48% of women present with atypical symptoms (dyspnea without chest pain) - maintain high index of suspicion 5

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Stroke/CVA - Time-Critical Management

"Time is Brain" - ED personnel must assess suspected stroke patients within 10 minutes of arrival. 1

Prehospital Actions:

• Use validated stroke screening tool (Cincinnati Prehospital Stroke Scale or Los Angeles Prehospital Stroke Screen) 1
• Establish exact time of symptom onset or last known normal - this determines thrombolytic eligibility 1, 2
• Administer supplemental oxygen only if saturation <94% 1, 2
• Do NOT treat hypertension in the field unless systolic BP <90 mmHg 1, 2
• Provide prearrival hospital notification - significantly increases fibrinolytic therapy rates 1, 2
• Transport directly to stroke center when possible 1, 2

ED Management:

• Establish/confirm IV access immediately 1
• Obtain blood samples: complete blood count, coagulation studies, blood glucose 1
• Order emergent non-contrast CT scan of brain - this takes priority over most other tests 1
• Activate stroke team 1
• Obtain 12-lead ECG (does not take priority over CT but identifies atrial fibrillation/MI as embolic source) 1

Blood Pressure Management for Thrombolytic Candidates:

• BP must be <185/110 mmHg before tPA administration 1, 2
• Options: Labetalol 10-20 mg IV over 1-2 minutes (may repeat once), or Nicardipine IV 5 mg/hr titrated up by 2.5 mg/hr every 5-15 minutes (maximum 15 mg/hr) 1

Critical Pitfall:

• Avoid delaying transport to administer field medications - rapid transport to stroke center is the priority 2

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Severe Dyspnea

Assess for life-threatening causes requiring immediate intervention: tension pneumothorax, pulmonary embolism, acute pulmonary edema, or airway obstruction.

Immediate Actions:

• Administer high-flow oxygen to maintain saturation ≥94% 1
• Assess airway patency - look for foreign body obstruction 1
• Obtain vital signs including pulse oximetry 1
• Perform focused cardiovascular and pulmonary examination 1
• Obtain 12-lead ECG - dyspnea may be anginal equivalent in ACS 5

If Foreign Body Airway Obstruction Suspected:

• Ask "Are you choking?" - if victim nods without speaking, this confirms severe obstruction 1
• Perform abdominal thrusts (Heimlich maneuver) for conscious victims 1
• If victim becomes unconscious, begin CPR and look for object each time airway is opened 1

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Status Epilepticus

Status epilepticus is a neurologic emergency requiring immediate intervention to prevent permanent neurologic damage and death. 7

Initial Management:

• Ensure airway patency and provide supplemental oxygen 7
• Establish IV access immediately 7
• Check blood glucose - hypoglycemia is a reversible cause 7
• Administer benzodiazepines as first-line therapy 7
• Protect patient from injury during seizure activity 7
• Monitor vital signs continuously 7

Critical Consideration:

• Prolonged seizures cause increased intracranial pressure and neurogenic respiratory failure - aggressive management prevents these complications 7

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Universal Principles Across All Emergencies

The ABC Approach Remains Fundamental:

• Airway: Ensure patency, consider intubation for unresponsive patients or those unable to protect airway 1
• Breathing: Provide supplemental oxygen for hypoxemia (saturation <94%), avoid hyperventilation 1
• Circulation: Establish IV access, obtain baseline studies, begin appropriate resuscitation 1

High-Quality CPR When Indicated:

• Compression rate: at least 100/minute 1
• Compression depth: at least 2 inches (5 cm) 1
• Allow complete chest recoil after each compression 1
• Minimize interruptions in compressions 1
• Compression-to-ventilation ratio: 30:2 until advanced airway placed 1
• Use AED/defibrillator as soon as available 1

Documentation Essentials:

• Record exact time of symptom onset or last known normal - critical for stroke and ACS management 1, 2, 5
• Document all interventions with timestamps 1
• Note response to treatments 1