Section 1
The ABC Approach to the Critically Ill Patient
Introduction
by Donna Venezia History of the ABC’s
The basic ABC algorithm was initially
designed and implemented on a large
scale in the early 1960’s for those
requiring cardiac-pulmonary
resuscitation. The order has recently
been changed to the CAB for those
who have suffered a cardiac arrest
(See BLS/ACLS – Cardiac Arrest
section). Twenty years later the
American College of Surgeons again
modified this sequence for patients
with acute traumatic injuries. Over the
subsequent years, there have been
many variations and modifications for
the variety of critically ill patients
presenting to an emergency
department. Most recently, the addition
of point-of-care testing with ultrasound
has been incorporated into algorithms
further to refine the accuracy of initial
treatment in the critically ill.
Goals of approaching any
critically ill patients are
• Rapidly identify and manage life/
brain-threatening conditions before
the exact diagnosis is made.
• After initial stabilization, follow with
full history, exam, time-consuming
lab/radiological testing and reach the
final diagnosis.
Identifying A Critically Ill
Patient
Triage is a reliable method to quickly
select from a large group of waiting
patients, those who may have a
potential illness requiring time-critical
management to save a life or the brain.
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As a standard structure, currently, all
modern emergency departments have a
triage unit to prioritize the patients. It
aims to select more critical patients as
e a r l y a s p o s s i b l e a n d c re a t e a n
appropriate patient flow in the emergency
department. However, triage can be done
in the field by EMS staff, and patients
may directly bring to the resuscitation
room.
Potential critically ill patients
may present with:
• altered mental status (unresponsive or
confused/agitated)
• noisy respiration (gurgling, stidor,
wheezing)
• inability to speak normally (acute
hoarseness or inability to articulate
words)
• respiratory distress (rapid/deep or slow/
shallow/agonal respirations)
• acute weakness or inability to ambulate
(diffuse/focal muscle weakness or light-
headedness/syncope)
• acute torso discomfort (may be
associated with radiation to jaw,
anterior neck or shoulder/medial upper
arms) suggestive of an MI/
cardiovascular problem.
• severe acute headache
• intractable seizure (may not show
muscular signs after a period of time)
• history of significant trauma, drug
ingestion, exposure, suicidal/homicidal
ideation
• significant vital signs abnormalities
(age-dependent)
Point of Care Testing
• adjunct tests/equipment that help guide
early decision-making
• results should be back within seconds
to minutes, not hours!
The ABCDEF Sequence
• Each letter represents a crucial body
system that, if significantly disrupted
and left untreated over hours rather
than minutes, can result in death or
brain damage.
• The order is performed sequentially to
avoid skipping crucial steps and
generally to manage the most serious
first, however, the sequence can and
should be performed simultaneously
(horizontal approach) in those with
multiple life-threatening conditions if
there are enough team members.
Modify as appropriate to the individual.
• Because management may need to be
simultaneous, the team approach is
crucial in successfully resuscitating any
critically ill patient.
• It is also important to emphasize that
the availability of various treatment
modalities at each medical facility.
Meaning of the letters in the ABCDEF
sequence:
A = Airway Disorders with C-spine control
B = Breathing Disorders
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C = Circulation/Cardiovascular Disorders
D = Disability (Neurological Disorders)
E = Exposure/Decontamination
F = F e v e r ( E x t re m e Te m p e r a t u re
Disorders)
How to approach the critically ill
patient using the ABCDEF algorithm
For each letter or body system:
• obtain a brief, focused history and
exam
• obtain available point-of-care testing to
aid in the evaluation/management
• initiate management for any acute life or
brain threatening condition
• then, proceed to the next letter and
repeat
• if no intervention is needed, quickly
p ro c e e d t h ro u g h t h e s e q u e n c e .
(Evaluation of a normal person should
take just a few minutes or even
seconds.)
A – Airway with C-spine
Control
Focused clinical assessment for
impending/actual airway compromise:
• noisy respirations (gurgling, stridor,
choking sounds) with or without
retractions
• drooling, inability to swallow secretions,
leaning forward in a tripod position
• throat swelling sensation with or
without pain
• change in voice associated with
symptoms of bacterial infection or
allergy (hoarseness, “hot potato” voice)
• active retching or vomiting with an
inability to turn or move to protect from
aspiration
• oral exposure to fire/steam inhalation,
chemicals, acids/alkali
• neck trauma with crepitus over larynx or
expanding hematoma
Point of Care Testing
• generally, none required for complete
obstruction
• soft tissue neck X-ray (for potential/
partial airway obstruction only)
• indirect laryngoscopy (for potential/
partial airway obstruction only)
• fiberoptic laryngoscopy (for potential/
partial airway obstruction only)
• u l t r a s o u n d ( f o r i d e n t i fic a t i o n o f
cricothyroid membrane or assessment
proper endotracheal tube placement)
Emergency Equipment for Managing
Airway Problems
1. nasal or oral airway devices
2. suction devices (rigid tip and/or small
flexible tip)
3. i n t u b a t i o n e q u i p m e n t ( i . e . ,
laryngoscopes with ET tubes of
various sizes)
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4. airway adjuncts for difficult airways –
i.e. LMA, iGel, Bougie, video
laryngoscope, fiberoptic laryngoscope,
etc.
5. Magill Forceps for foreign body
removal
6. Pre-intubation supplies – supplemental
Rapid Sequence Intubation
wall and/or tank oxygen, RSI
medication, sedation medication, oral
numbing medication
7. “failed airway” kit – cricothyroidotomy
kit with appropriate sized Shiley or
endotracheal tubes
8. capnography and/or ultrasound to
assess for proper endotracheal tube
placement
9. appropriately sized cervical collars
Management Algorithm for Critical
Airway Problems
• possible c-spine injury – employ the
second person to immobilize c-spine.
Only jaw thrust maneuver is allowed in
this situation (see caveat 1)
• To n g u e o b s t r u c t s a i r w a y i n a n
obtunded patient – perform either head
tilt, chin lift, or use jaw thrust
maneuvers if possible. See BLS/ACLS.
• obtunded, without trauma – position
patient on the side to avoid tongue
obstruction
• Patient unable to be positioned – place
nasal or oral airway. Avoid oral airway if
partially awake since may cause
gagging/vomiting. Avoid nasal airway if
midface trauma.
• pharyngeal secretions, blood, and/or
vomitus – suction
• obstructing foreign body – perform
abdominal thrusts/chest compressions
per BLS or if visible, attempt to retrieve
with McGill forceps.
• laryngeal edema; likely anaphylaxis –
administer IV/IM Epinephrine, likely
hereditary angioedema – administer
C1 esterase compound.
• signs of imminent or complete airway
obstruction, unrelieved from above –
attempt intubation with the most
appropriate device by the most
experienced provider. May attempt
BVM ventilation first, especially in
children with epiglottis, as a
temporizing measure.
• unable to intubate or BVM –
immediately perform cricothyroidotomy;
avoid if laryngeal fracture a concern –
p r e f e r fib e r o p t i c i n t u b a t i o n o r
tracheostomy in OR if possible. (See
cricothyroidotomy technique)
Caveats
1. The airway is always associated with
the phrase, “with c-spine control”.
Before performing any airway
procedures, one must quickly assess
the likelihood of a c-spine injury. If
there is a possibility of an injury in an
unresponsive patient, i.e. found at the
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 bottom of the stairs, or on the side of
the road, unconscious, then assume
an injury and protect the c-spine by
simply immobilizing as best possible.
Typically a C-collar is slid under the
back of the neck while someone
immobilizes the head. If airway
management is required, the front of
the collar can be opened or removed,
as needed, while someone stabilizes
the head in relation to the torso.
Nothing further needs to be done in
the primary survey to evaluate the c-
spine.
2. An unresponsive patient has a
potential for airway compromise and
subsequent aspiration. However, since
proper intubation is time intensive, you
may avoid intubation in these patients
until the primary sequence is
completed, unless the patient is
actively retching. Have someone
p re p a re t h e e q u i p m e n t a s t h e
sequence is being completed and
continue the evaluation since
treatment of a condition found later in
the sequence may improve the mental edema, laryngeal cartilage fractures
status, making intubation unnecessary secondary to trauma
such as low blood sugar. Be prepared
• laryngeal cartilage fractures secondary
to log roll quickly if the patient vomits.
to trauma
Conditions causing airway
• expanding paratracheal hematoma
compromise
• tracheomalacia
• unresponsive patient with tongue
blocking the airway an unresponsive • pharyngeal malignancies
patient who is unable to protect from
aspiration of blood/vomitus, etc. B – Breathing Disorders
Focused clinical assessment for
• an unresponsive patient who is unable evidence respiratory failure
to protect from aspiration of blood/
vomitus, etc. Cyanosis, inability to speak full
sentences without needing a breath,
• infections, i.e. epiglottis,
confused/agitated or unresponsive with:
retropharyngeal abscess, etc.
1. Rate: too slow, shallow, agonal,
• allergic reactions/anaphylaxis, airway
gasping (age-dependent, generally
burns, i.e. steam, chemicals, alkali/
rates <10 in an adult are abnormal)
acids, etc.
2. Rate: too fast and/or deep (again age-
• airway burns, i.e. steam, chemicals,
dependent but >20 in a resting adult is
alkali/acids, etc.
abnormal, and > 30 is significantly
• other causes of edema, i.e. ACE abnormal)
inhibitors, hereditary angioneurotic
3. Abnormal lung sounds:
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• unilateral decreased breath sounds
(either dull or hyper-resonant)
• wheezing or poor air movement
• rales (fine crepitation) or rhonchi
4. Chest wall abnormalities affecting
breathing dynamics – flail chest/open
punctures
Obtain as much focused history/exam as
able to help define the need for a
particular emergent treatment strategy for
the common causes of critical respiratory
conditions. For example, two common
causes of severe respiratory distress are
pulmonary edema and COPD. Both may
present with wheezing (“cardiac asthma”
in CHF), pedal edema and/or JVD,
making the decision for which type of
emergent management strategy difficult.
Obtain as much focused history/exam in
a brief period of time, i.e. family states
heavy smoker with similar episodes in the
past, all resolved with inhaler therapy or
the patient has a history of recent ECHO
with very poor ejection fraction, etc. to
help make a decision about treatment.
If still not clear as to a management
strategy, add point-of-care testing, i.e.,
lung sonography or upright portable CXR.
Point-of-Care testing
• pulse Oximeter
• C02 waveform monitor
• arterial (ABG) or venous (VBG) blood
gas
• portable CXR (upright, if possible)
• pulmonary ultrasonography:
evaluate lung sliding for
pneumothorax
assess costophrenic angles for
effusion/hemothorax
assess lung field segments for A/B
lines, signs of consolidation
Management Algorithm for Acute
Respiratory Disorders
•fix all upper airway critical issues
first
• slow, agonal respirations or significant
respiratory acidosis on ABG – provide
BVM ventilation and administer Narcan.
• rapid breathing with hypoxia – provide
supplemental O2 by the non-rebreather
mask to keep O2 saturation greater
than 94%.
• sucking chest wound – seal with an
occlusive dressing (3 sides only)
• tension pneumothorax – place a 14
gauge needle, immediately followed by
a chest tube
• massive hemothorax/pleural effusion –
drain fluid, contact trauma surgeon
since may need transfusion/transfer to
OR for massive hemothorax
• no improvement in oxygenation despite
placement of non-rebreather mask or
above procedures, either –
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 a l l o w t h e p a t i e n t t o b re a t h e
spontaneously under tightly held BVM
mask with PEEP valve on exhalation
port and 15 L/min nasal cannula O2
placed under the mask or
provide NIV (non-invasive
ventilation) with CPAP/BiPAP
• patient agitated and unable to tolerate
masks – administer IV Ketamine.
• Signs of obstructive pulmonary disease
(COPD/asthma) – administer
inhalational beta agonist. Consider
additional therapy (i.e., ipratropium,
Prednisone, Magnesium, epinephrine,
etc.).
• Signs of acute pulmonary edema with
adequate BP – administer repetitive or
continuous doses of Nitroglycerin SL,
spray or IV. Consider additional drug
therapy (i.e. Furosemide, etc.)
• respiratory distress unresponsive to
above therapy – intubate and
mechanically ventilate
Emergency Equipment for Managing
Breathing Emergencies
1. Noninvasive ventilator NIV
2. BVM (bag-valve-mask) with O2 supply
and added PEEP valve
3. additional wall or tank for an additional
source of O2 (nasal cannula)
4. 14 gauge catheter-over-the-needle
5. various sized chest tubes
Caveats
1. fast RR with clear lungs may be
2. Severe hypoxia unresponsive to
secondary to psychogenic
hyperventilation, primary brain lesions,
metabolic acidosis, poisoning, sepsis,
pulmonary embolus or pericardial
tamponade:
a. consider paper bag breathing if O2
3. It is important to recognize that
sats normal, no acidosis, and
hyperventilation syndrome most likely
(i.e., anxious with carpopedal spasm).
b.C o n s i d e r s p e c i fic p o i s o n i n g
antidotes, i.e., cyanide antidote or
hyperbaric/100% O2 for CO
poisonings. See the toxicology section.
c. Sepsis, Pulmonary embolus, and
pericardial tamponade management
are discussed in more depth in the
circulatory section since the primary
c r i t i c a l p re s e n t a t i o n i s u s u a l l y
circulatory collapse.
d. Obtain ABG/VBG if metabolic
acidosis likely, manage most likely
cause. See acid/base section.
therapy, particularly with clear lungs,
m a y b e d u e t o s h u n t i n g f ro m
congenital heart disease which, in a
neonate, may respond to the
administration of PGE1 (prostaglandin).
oxygenation and ventilation are
different. A patient may not be
hypoxic, especially if given
supplemental O2 but may still be in
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 acute ventilatory failure. (Only 250 cc
of oxygen is used by the resting adult
per minute. However, 6-10 L of air
must be moved per minute to
adequately ventilate a normal adult
and prevent the rise in pCO2.)
Conditions Associated with
Respiratory Failure
• Pulmonary edema
• COPD/asthma
• severe pneumonia
• ALI/ARDS from any cause (drugs,
aspiration, etc.)
• tension pneumothorax
• chest wall dysfunction, (flail chest,
muscular weakness, open sucking
wound)
• respiratory depressants (narcotic OD,
sedative OD)
• bronchiolitis
• pulmonary embolus, air/amniotic fluid/
fat embolus
• massive hemothorax or massive pleural
effusion
• exhaustion from prolonged
hyperventilation
• chronic lung conditions: cancer,
sarcoidosis, fibrosis, etc.
C – Circulation Disorders
Poor perfusion, Hypertensive crisis, Acute
MI
Clinically assess for poor perfusion
associated with
• tachycardia: > 100 abnormal in adults,
> 150 frequently clinically symptomatic.
• bradycardia: < 60 abnormal, < 30
frequently clinically symptomatic.
• hypotension: systolic < 90
• Perfusion and cardiovascular
assessment may include
Skin – i.e., cool, diaphoresis, pale,
poor capillary refill, hives, erythema
Mental status changes – i.e.,
confusion, slow responses, agitation
Rhythm/quality of pulses in all four
extremities
Assessment for hidden blood loss,
i.e., rectal for melena, pelvic instability,
pulsatile abdominal mass
history: internal/external bleeding/
trauma, vomiting/diarrhea, oral intake/
urine output, fever, diabetes/renal
i n s u ffic i e n c y / c a r d i a c f a i l u r e ,
medications, drug abuse/OD, last
menses
Clinically assess for hypertension
associated with
• signs of end-organ damage/
involvement, i.e., encephalopathy and/
or papilledema, pulmonary edema,
cardiac ischemia, renal impairment,
and/or neurological abnormalities
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• pregnancy (generally 3rd trimester/first
weeks postpartum); any new elevation
of BP >140/90, particularly associated
with a headache, abdominal pain,
jaundice, shortness of breath and/or
visual disturbances
Clinically assess torso discomfort for
likely MI
• description varies; besides chest
discomfort, symptoms may include
either/or epigastric discomfort, mid-
back discomfort, radiation to shoulders,
anterior neck, jaw or upper, inner arms.
• Note: There are many serious causes of
torso pain, i.e., simple pneumothorax,
cholecystitis, pancreatitis, bowel
perforation, etc.; work-up and
management would be performed
during the secondary evaluation unless
there are signs or symptoms of
circulatory collapse. The evaluation of
torso discomfort in the initial
assessment should an emergent EKG
to pick up an MI.
Point-of-care testing
• EKG (perform within 10 minutes of ED
presentation; may include right-sided
leads RV3,4 and posterior leads V8, V9)
• Cardiovascular ultrasound to include
assessment of:
LV cardiac contractility – normal,
hyperactive, weak
the ratio of right to left ventricle size
p e r i c a r d i a l flu i d / t a m p o n a d e
physiology
aortic root dilation/dissection flap
IVC collapsibility with inspiration
evidence of free intraperitoneal fluid
evidence of abdominal aortic
aneurysm and/or dissection
evidence of DVT in femoral veins
• Telemetry monitor strip
• ABG/VBG with electrolytes
•Hemocult paper (only needed if any
question of blood/melena in stools)
• Urine beta-HCG for critical childbearing
age females
Emergency Equipment for Managing
Cardiovascular Emergencies
1. pelvic binders/gauze for compression/
tourniquets
2. defibrillator/external pacemaker
3. large bore IV’s and 0.9% saline or
Ringer lactate fluids
4. various sized IO insertion kits
5. central line kits (only for large bore
sheath placement, if necessary)
6. thrombolytics or ability to access PCI
(percutaneous coronary intervention)
facility
7. immediate access to O negative blood
8. straight catheter/Foley catheter (for
pregnancy check) and monitoring urine
output
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9. Sengstaken-Blakemore tube
Management Algorithm for Critical
Cardiovascular Disorders
• Management of Poor Perfusion
place two large bore IV’s and attach
telemetry monitor to all (may collect
various labs including blood cultures,
but should send type and crossmatch
now)
evidence of external bleeding,
unstable pelvis – apply pressure/
binder; in rare cases tourniquet
patient in the 3rd trimester of
pregnancy – displace uterus to left/
wedge under right flankunable to start
IV – attempt IO (intraosseous) with 300
mmHg pressure cuff over the fluid bag
to increase flow rate (Central line
sheaths, if unable to start IO).
unable to start IV – attempt IO
(intraosseous) with 300 mmHg pressure
cuff over the fluid bag to increase flow
rate (Central line sheaths, if unable to
start IO).
if no evidence of cardiac failure –
administer bolus 10-20cc/kg 0.9% NS/
R i n g e r s s o l u t i o n . ( F u r t h e r flu i d
administration determined by clinical/
sono evaluation, risk/benefit, i.e.,
permissive hypotension and clinical
response, i.e., urine output).
Evidence of unstoppable internal
bleeding – immediate consultation with
appropriate specialty, i.e., surgery, OB,
GI, etc. Consider various meds to
attenuate bleeding, i.e., Tranexamic
Acid, Terlipressin for esophageal bleed
or Oxytocin for OB bleed. Consider
various procedures to stop internal
bleeding, i.e., Sengstaken-Blakemore
tube placement for esophageal bleed,
uterine massage post-delivery, etc.
severe blood loss and/or persistent
unstoppable bleeding – transfuse O-
negative units until type specific or fully
cross-matched blood available
unstable tachydysrhythmia (not
sinus, multifocal atrial tachycardia,
junctional) – cardiovert per ACLS
unstable bradydysrhythmia –
administer meds (i.e., Atropine, etc.)/
place external pacemaker per ACLS
evidence of rhythm disorder is
associated with K+ abnormality by the
lab, clinical history (i.e., renal failure,
DM) and/or EKG findings – administer
a p p ro p r i a t e h y p e r / h y p o k a l e m i a /
magnesemia therapy
dysrhythmia unresponsive, with
evidence of thyroid storm or history of
drug OD, consider thyroid management
or specific antidotes: NaHCO2 for fast
Na+ channel OD (TCA, tricyclic
antidepressants), Digibind for Digoxin
toxicity, etc.
evidence of aortic dissection by
clinical, sono evaluation – administer b-
blocker first, i.e., Esmolol, then
antihypertensive, i.e., Nitroprusside,
contact cardiovascular surgery
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 evidence of obstructive shock by
clinical/sono – treat appropriately as
guided by diagnosis, i.e.,
thrombolytics/interventional radiology
for pulmonary embolus,
pericardiocentesis for tamponade,
chest tube for tension pneumothorax,
etc.
no evidence of acute volume loss
and/or no response to fluids or
previous therapies – start pressors,
Norepinephrine, Dopamine,
Epinephrine, Dobutamine, etc., i.e., Epi
for anaphylaxis, Dob/Norepi for
cardiogenic shock, Norepi for sepsis,
etc.
if no response to above, consider
either:
1. a d r e n a l c r i s i s – s t a r t I V
Hydrocortisone. (Dexamethasone, if
choose to perform testing
concurrently.) and/or
2. drug OD (i.e., b-blocker or calcium
channel blocker – treat with high dose
Insulin/glucose)
Management Algorithm for Severe
Hypertension associated with
• e v i d e n c e o f e n d - o rg a n d a m a g e
(ischemia, heart failure, encephalopathy,
etc.) – administer IV antihypertensive
(Labetalol, Nitroprusside, etc.) Avoid
pure beta blockers if suspect cocaine
overdose.
• evidence of hemorrhagic stroke,
thrombotic stroke, subarachnoid
hemorrhage (See Disability Section)
• pregnancy and new elevation of BP
>140/90 – re-evaluate in 15 minutes
• pregnancy with evidence of pre-
eclampsia/eclampsia (i.e., headache,
nausea/vomiting, abdominal pain, visual
disturbances, shortness of breath,
hyperreflexia, seizures – with or without
proteinuria) – or severe hypertension BP
160/110 – administer MgSO4 and
initiate antihypertensive, (i.e.,
Hydralazine, Labetalol, or Nifedipine),
immediate OB consult.
Management Algorithm for Torso
Discomfort
• acute torso discomfort with MI
documented by EKG – contact
cardiology for immediate PCI/transfer
a n d / o r a d m i n i s t e r t h ro m b o l y t i c s
depending on location and timing of
event per ACLS
• acute MI by EKG (whether eligible or
not for PCI/thrombolytics) – monitor for
dysrhythmia, i.e., ventricular fibrillation,
etc., administer Aspirin, follow protocols
per local cardiologist.
• high suspicion of cardiac ischemia but
EKG not diagnostic – repeat in 10-15
minutes.
Causes of critical cardiovascular
conditions
• dehydration
• acute blood loss (internal and external)
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• sepsis D – Disability (Neurological/ Point-of-Care Adjuncts

• drug toxicity/OD
Psychological Disorders) • fingerstick glucose measurement
Clinically assess for
• cardiogenic shock • non-contrast head CT to be performed
• depressed consciousness (lethargic,
in less than 30 minutes
• anaphylaxis confused, comatose) (may use GCS to
assess the degree of unresponsiveness) • acute malaria screen in appropriate
• neurogenic shock
environments
• pupil size, symmetry, and reactivity
• adrenal crisis
• rapid HIV test
• agitation, delirium (waxing and waning
• thyroid storm
level of consciousness associated with • electrolytes (Na+, and Ca++, in
• obstructive shock confusion/disorientation and/or particular), if available, on ABG/VBG
hallucinations – typically, visual/tactile) assessment, sono for evaluation of
pulmonary embolus papilledema
• acute focal weakness/paralysis, or
pericardial tamponade inability to speak • sono for evaluation of papilledema
tension pneumothorax
• severe, acute headache, nuchal rigidity Emergency Equipment Needed for
gravid uterus compressing IVC Neurological Management
• signs of status epilepticus, including
subtle seizure-like activity (i.e., twitching 1. CT scanner
• tachydysrhytmias/bradydysrhythmias
with or without electrolye disorders e y e l i d s , s t i ffn e s s , p e r s i s t e n t
u n re s p o n s i v e n e s s a f t e r o b v i o u s 2. access or ability to transfer to
• symptomatic hypertensive with or seizure-like activity) neurosurgical equipped OR
without pregnancy
3. LP tray
• acute psychiatric disorder with either
• acute MI suicidal or homicidal ideation 4. leather restraints
• acute aortic dissection/rupture
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5. stretchers that allow for head elevation
Management Algorithm for Critical
Neurological Disorders
Acute Agitation/Delirium Algorithm
• in all patients attempt to talk first to
calm and remove anything that might
cause injury
• agitation, particularly in young patients
or possible drug toxicity/withdrawal –
administer Benzodiazepines. Avoid in
elderly with dementia; likely to increase
confusion. Monitor respirations in all.
• agitation, with signs of hypoxia,
hypoperfusion – consider Ketamine
starting dose 1mg/kg with continued
ABC resuscitation
• agitation, with a known history of
psychiatric disorder or likely new-onset
psychiatric disease – administer
psychotropic agent, i.e., Haldol IV, IM.
with or without Benzodiazepine.
• agitation, unable to calm with above
and/or patient an imminent danger to
self/others – call for ‘man-power’
support and apply four-point restraints.
(Provide close monitoring of the patient
and remove restraints as soon as
deemed safe)
Acute Mental Status Depression
Algorithm
• fix the airway, breathing and circulation
conditions first
• Check fingerstick glucose – if low
administer bolus or drip of D50/D25 or
D10 depending on patient age. May
give IM Glucagon if unable to start IV
and patient cannot swallow. Administer
Thiamine with the glucose. (Narcan
should have already been given under
section B).
• if GCS < 9 after ABC resuscitation – the
patient likely requires intubation to
protect from aspiration – prepare
equipment
•History acute fever, headache,
without focal neurological signs, recent
seizure history or impaired immunity
and exam/sono shows no papilledema
– check malaria smear, rapid HIV test,
perform LP, initiate empiric antibiotic
treatment (possible steroids first), based
on age/likely etiology. Before any meds
given attempt to quickly determine if
allergic, from family, old records, etc.
• History acute fever, headache, with
focal neurological signs or seizures,
impaired immunity and/or exam/sono
shows papilledema – do not perform
immediate LP – check malaria smear,
rapid HIV test, initiate empiric antibiotic
treatment (possible steroids first), based
on age/likely etiology. Before any meds
given, attempt to determine if allergic,
from family, old records, etc. Follow
with CT and possible LP, ASAP.
• consider status epilepticus in all non-
responsive patients, (motor signs may
be minimal) or if not awakening
between seizures:
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 check electrolytes – if
hyponatremic administer 2cc/kg
over 10 min of 3% NaCl (max
100cc)
• Normal CT, likely thrombotic stroke –
Third trimester/post delivery –
administer MgSO4/consult OB
likely INH OD or neonatal
dependency – administer
Pyridoxine.
• New intra-cerebral bleed on CT –
all others – start with
Benzodiazepines, consult
neurology
• if no improvement with above – obtain
• epidural/subdural/nontraumatic SAH on
head CT; follow management in the
section below.
Focal Neurological Signs/AMS (with or
without head trauma) and/or a Sudden,
• Evidence of acute herniation – raise the
Severe Headache Algorithm
• obtain a head CT in all patients, if
available
• normal CT, likely SAH by history (onset
> 6 hours), perform LP – nontraumatic
blood/ xanthochromia, immediate
neurosurgery consultation, control BP <
160/90. See SAH guidelines.
initiate TPA/endovascular therapy per
protocols, control BP to <185/110. If
unable to use TPA, do not drop BP
unless >220/120. See thrombotic stroke
guidelines.
control BP to <140/90; reverse
anticoagulants. See hemorrhagic stroke
guidelines.
CT – immediate neurosurgery
consultation for possible OR/IR
intervention.
head of bed 30-45 degrees (assuming
no spine trauma), consider Mannitol,
3% NS, and/or mild, brief
hyperventilation. Consider IV
dexamethasone for a tumor with
herniation.
Causes of critical neurological
disorders
• conditions affecting airway, breathing
and/or circulation
• metabolic disorders:
Hypoglycemia/hyperosmolar
coma/DKA
thyroid disorders
electrolyte disorders (primarily Na+
and Ca++)
liver/kidney failure, etc.
• drug toxicity/OD or drug withdrawal
syndromes
• acute psychiatric disorders
• mass lesions (hemorrhage, tumors,
abscesses)
• infections – meningitis/encephalitis
(bacterial, fungal, viral, parasitic
infections including cerebral malaria)
• status epilepticus and post-ictal states
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• stroke syndromes – thrombotic,
intracerebral hemorrhagic, SAH
E – Exposure
Clinically evaluate
• areas hidden by clothing/body position
for missed lesions (rashes/stab/gunshot
wounds) by undressing and log rolling.
• the body for evidence of self/child/
elder/domestic abuse and evidence of
IV drug abuse.
• for possible contaminated clothing/skin:
substances absorbed through the skin
(i.e., hydrocarbon pesticides), caustics,
radiation or objects causing continued
burns, etc.
Point-of-care testing
• none
Management Algorithm for Exposure
Disorders
• signs of child or self-abuse – provide
safe location and separate from
abusers
• evidence of hidden bleeding – manage
as per Section C
• evidence of clothes/skin contamination
– decontaminate, according to toxicity
and protect self and others in the
process (self-protection should be
implemented at the onset of patient
evaluation)
• re-dress patient in a gown to prevent
cooling and provide privacy
Equipment Needed for Exposure/
Decontamination
1. shower with containment for water
runoff
2. protective gowns, masks, gloves for
staff
3. i s o l a t i o n r o o m w i t h a i r v e n t
containment
4. shears/metal cutter
F – Fever (Extreme
Temperature Disorders)
Clinically Assess
• skin warmth/coolness
• skin color (pale/red), dryness,
diaphoresis
• muscle rigidity, shivering
• thyroid for nodules/enlargement
• obtain the history of medications
(recent psychotropic/succinylcholine,
anesthetics, etc.), drug abuse,
endocrine disease, outdoor exposure,
excessive exercise
• Note: normal temperature is 98.6 F or
37 C. Any temperature above 100.4 F or
38 C rectally is considered a fever.
H o w e v e r, i t i s t h e e x t re m e s o f
temperature that require emergent
management, usually > 105 F (40.5 C)
or < 95 F (35 C)
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Point-of-care testing • convection (evaporation) methods, i.e.,
tepid water spray on skin and fan and/
• Thermometer: oral -affected by mouth
or
breathing, drinking warm/cold fluids
• conduction heat loss by placing ices
• axillary – add a point to correlate with packs over major vessels, i.e., groin,
rectal temperature.
axilla or neck. (Ice tub immersion
• rectal – most accurately reflects core possible, but not able to easily monitor.)
temperature.
• cool IV fluids
Emergency Equipment Required
• if severe temperature elevations –
initiate core cooling: ice water lavage of
• fan
the bladder, thorax, stomach and
• ice packs prevent shivering with drugs such as
dexmedetomidine / Butorphanol.
• lavage tubes
• evidence of anticholinergic,
• warning blankets
sympathomimetic, MAOI poisoning –
• rectal temperature probe consider antidotes.
Management Algorithm for Critical • evidence of neuroleptic malignant
Temperature Extremes syndrome – stop neuroleptics, consider
various antidotes See management of
Hyperthermia Algorithm neuroleptic malignant syndrome.
• initiate heat loss for all by • evidence for thyroid storm – initiate b-
blockade, cortisone, PTU, then iodine
last
Hypothermia Algorithm
• mild to moderate temperature decline –
30-35 degrees – external rewarm, i.e.,
blankets and initiate warmed IV fluids,
and heated inspired air heated to 45
degrees
• severe, <30 degrees – consider
a d d i t i o n a l c o re re w a r m i n g , i . e . ,
peritoneal lavage, thoracic lavage,
esophageal tubes, etc.
• evidence of myxedema coma –
administer thyroxine and
hydrocortisone, avoid rapid rewarming
Causes of critical heat/cold related
conditions
• exposure to extreme environmental
temperature conditions
• endocrine disorders (especially hyper/
hypothyroidism)
• t o x i n s / O D ’s ( a n t i c h o l i n e r g i c s ,
sympathomimetic, MAOI drugs, ASA,
etc.)
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• sepsis (for both extremes)

• neuroleptic malignant syndrome

• malignant hyperthermia associated with

anesthetics

After the sequence is completed, quickly

re-evaluate the patient to see if
intervention(s) resulted in improvement.

Then follow the ABC’s with:

• evaluation of past medical history,

medication history, and allergy history, if
not already performed

• perform the secondary survey (i.e.,

detailed history and a complete exam)

References and Further Reading, click

here.

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