How should I manage an unresponsive adult patient in the emergency department?

Management of an Unresponsive Patient in the Emergency Department

In the ER, immediately ensure scene safety, check responsiveness by tapping and shouting, simultaneously assess breathing and pulse within 10 seconds, and if the patient has no pulse or only gasping respirations, begin CPR immediately with chest compressions at 100-120/minute while activating the code team and retrieving the defibrillator. 1, 2

Initial Assessment (First 10 Seconds)

Scene Safety and Team Activation

• Verify scene safety before approaching the patient 1
• In the ER setting with multiple providers available, immediately activate the code team while simultaneously beginning assessment—one provider checks responsiveness, another assesses breathing/pulse, a third retrieves the crash cart and defibrillator, and a fourth prepares airway equipment 1

Rapid Assessment Protocol

• Check responsiveness by tapping the shoulder and shouting at the patient 1
• Simultaneously assess for breathing and pulse—do not perform these sequentially 1, 2
• Limit pulse check to no more than 10 seconds to avoid delaying chest compressions 1
• Look specifically for absent breathing or only gasping respirations, as gasping occurs in 40-60% of cardiac arrest victims and represents agonal breathing, NOT normal breathing 2

Critical Decision Point: Cardiac Arrest vs. Non-Arrest

If No Pulse OR Uncertain Pulse with Gasping/No Breathing:

• Assume cardiac arrest and immediately begin CPR 1, 2
• Healthcare providers often incorrectly assess pulse presence; when in doubt after 10 seconds, start compressions as injury from compressions in non-arrest patients is rare 1

If Definite Pulse Present with No Normal Breathing:

• Provide rescue breathing at 1 breath every 5-6 seconds (10-12 breaths/minute) 1
• Recheck pulse every 2 minutes 1
• If pulse becomes absent, immediately begin CPR 1

If Pulse Present with Normal Breathing:

• Place patient in recovery position to maintain airway patency 3
• Monitor peripheral circulation when using recovery position 3
• Closely monitor and prepare for potential deterioration 1

CPR Protocol for Cardiac Arrest

Chest Compressions (Highest Priority)

• Begin compressions immediately—push hard and push fast 1
• Compression rate: at least 100-120 compressions per minute 1, 2
• Compression depth: at least 2 inches (5 cm) 1, 2
• Allow complete chest recoil after each compression to allow heart filling 1
• Minimize interruptions in compressions—any pause decreases CPR effectiveness 1
• Use 30:2 compression-to-ventilation ratio 1

Airway and Breathing

• Open airway using head tilt-chin lift maneuver 3
• Remove visible obstructions from mouth 3
• Provide bag-valve-mask ventilation with 100% oxygen while preparing for advanced airway 2
• After 2 minutes of CPR, check rhythm with defibrillator 1

Defibrillation Protocol

AED/Defibrillator Use

• Apply defibrillator as soon as available 1
• Check rhythm after 2 minutes of CPR 1
• If shockable rhythm (VF/pVT): Deliver 1 shock, immediately resume CPR for 2 minutes, then recheck rhythm 1
• If non-shockable rhythm: Resume CPR immediately for 2 minutes, then recheck rhythm 1
• Continue until advanced life support providers take over or patient shows signs of life 1

Special Considerations in the ER Setting

Team-Based Approach

• Unlike single-rescuer scenarios, ER teams should perform multiple actions simultaneously rather than sequentially 1
• Delegate roles immediately: one provider performs compressions, another manages airway/ventilation, a third operates defibrillator, a fourth administers medications 1

Common Pitfalls to Avoid

• Do not delay compressions to obtain "perfect" pulse assessment—if uncertain after 10 seconds, begin CPR 1
• Do not mistake gasping for normal breathing—gasping indicates cardiac arrest 2
• Do not mistake brief seizure activity for a primary seizure disorder—seizures may be the first manifestation of cardiac arrest 1
• Avoid excessive ventilation, which decreases venous return and cardiac output 2

Differential Considerations During Resuscitation

• Consider reversible causes (H's and T's): hypovolemia, hypoxia, hydrogen ion (acidosis), hypo/hyperkalemia, hypothermia, tension pneumothorax, tamponade, toxins, thrombosis (coronary/pulmonary) 2
• If history suggests hanging or trauma, maintain cervical spine precautions during airway management 3
• If suspected opioid overdose, administer naloxone per protocol while continuing resuscitation 1