ABC of Emergency Room Management1

Originally, the term “casualty” meant a seriously injured patient¹. In military parlance, the term was used to refer to the dead, wounded, and the sick who were termed “casualties”. The term “Casualty Ward” has been used in the works of William Shakespeare and Charles Dickens^{1, 2}. The early casualty departments treated casual attendees as well as real “casualties”. In 1962, following the report by Sir Harry Platt³, the department was renamed as “Accident and emergency service” and emergency medicine has evolved into a speciality in its own right and transition to the concept of the “Emergency room care” evolved.

The emergency room (ER) – especially in large teaching hospitals – is like a war zone. Considered to be one of the most challenging and stressful career options among the various specialities of Medicine, ER is a place where the narration of the clinical history by the patient, attendants, or the paramedical team; physical examination, resuscitation, stabilisation, and institution of specific treatment all have to occur almost instantaneously. Thus, it is not surprising that the ER is considered to be the “shop window” of the hospital as it is the part of the hospital most closely in contact with the public¹. While the speciality of emergency medicine is better evolved in developed countries, this speciality is still in its infancy in India.

The spectrum of patients seen in the ER includes diverse conditions such as multiple injuries, burns, drowning, exposure to extremes of temperature, poisoning and overdosage, acute medical emergencies such as acute myocardial infarction, cardiogenic shock, pneumothorax, stroke, seizures, coma due to various causes, acute surgical emergencies such as acute abdomen, and psychiatric emergencies among others. The initial management of all these conditions in the ER will be common and will constitute the ABC of ER management. The management protocols for each of these problems are highly specific and a detailed description of these is beyond the scope of this chapter. However, certain general principles have been outlined regarding the fundamentals of ER management. In this chapter, we have attempted to provide an overview of the ABC of ER care of adults, keeping in mind the facilities available in the ERs in India.

To provide quality care, the ER team caring for adults should comprise of an internist, general surgeon, orthopaedician and traumatologist, anaesthesiology and critical care expert, alongwith paramedical and nursing staff trained in ER care basic life support (BLS), cardio-pulmonary resuscitation (CPR), and advanced life support (ALS). Senior residents/ registrars, postgraduate student trainees, senior house officers in the above-mentioned specialities, often help the consultants in the patient management. Most hospitals have a protocol of one of the registrars being the team leader. In the setting of some tertiary care teaching hospitals, experts specifically trained in paediatric ER management may be available. The ER team is usually assisted by emergency radiology staff, ambulance crew, and porters for shifting patients.2

The ER should be located at a place that is easily accessible so that minimal time is lost in transferring the patients from the ambulance or other means of transport that has brought them to the hospital. It should be possible to swiftly shift the patient unhindered to an examination cubicle with facilities for providing advanced life support where stabilisation and resuscitation should begin.

In India, emergency medicine service is largely provided in “Casualty” often staffed by physicians who have no postgraduate qualifications and the post is temporary in most circumstances. Ambulances are mostly privately owned and operate on a fee for service base^{1, 4}.

The successful outcome of a patient presenting to the ER depends on a number of persons working together towards the same goals. The first link in the chain is the pre-hospital care provided by the paramedical service. However, this aspect of care is seldom available in India. The second link is the initial evaluation and resuscitation in the ER. The third link is the emergency investigations and specific specialist management⁵.

The actions taken during the first few minutes in the ER are critical to the survival of the patient. Although the sequence described below is outlined as a serial progression, in the practical setting, these activities often occur simultaneously. The initial assessment consists of the following: (i) primary evaluation; (ii) resuscitation; (iii) detailed secondary evaluation; and (iv) initiation of definitive treatment.

When a patient presents to the ER, primary survey includes a systematic, sequential assessment of the vital functions of the patient alongwith identification and treatment of life-threatening conditions. These constitute the ABC of emergency care (Table 1).

Adequacy of the airway must be first assessed. Attempt should be made to establish an airway while maintaining control of the cervical spine. The patient should be laid flat. The airway position is optimised to force the flaccid tongue forward and maximise the airway opening. If there is no suspicion of neck injury, the neck and head can be kept in the “sniffing position” with the neck flexed forwards and the head extended. The fingers of each hand are placed on the angle of the mandible just below the ears and the jaw is pulled forward to apply “jaw thrust” to facilitate the forward movement of the tongue without flexing or extending the neck. When airway access is a problem in patients who are lethargic or obtunded because of poisoning or overdosage, placing the patient in a head-down, left-sided position facilitates draining of the secretions or vomitus out of the mouth and allows the tongue to fall forwards. A sweeping movement with the gloved finger may be employed to remove obstruction or secretions. As a temporary measure, artificial oropharyngeal or nasopharyngeal airway device may be used to access the airway.

In trauma victims, care should be taken to avoid neck extension and the cervical spine must be stabilised by fitting a rigid collar and taping the forehead to the sides of the trolley.

The presence of a patent airway does not mean that ventilation is adequate. It is important to assess whether the breathing is adequate. This can be done 3by the “look, listen, and feel” approach⁶. The patient's chest must be adequately exposed and breathing movements should be assessed. The chest should be examined for any injuries that could compromise ventilation, and assessment should be carried out whether the breath sounds are equal and symmetrical. Feeling the movement of air can also help in assessing the adequacy of breathing. If tension pneumothorax, massive haemothorax, flail chest, or open (sucking) chest wounds are detected, immediate treatment is mandated¹.

If the patient is not breathing, and help is on its way, artificial respiration must be started. In the hospital setting this is done by using a standard bag and mask.

Cardiac arrest is diagnosed on the basis of two important clinical signs: (i) unconsciousness; and (ii) the lack of a major pulse and absence of signs of circulation (normal breathing, coughing, or movement)¹. According to the recent guidelines⁷, “lay rescuers” are no longer expected to perform a pulse check, but should initiate CPR if they detect the absence of signs of circulation. However, medical personnel should still perform a pulse check⁷.

As soon as cardiac arrest is diagnosed, help should be called for and BLS must be initiated⁷. If the carotid pulse is not felt for more than 10 seconds, chest compressions must be started for ensuring circulation. After locating the middle of the lower third of the sternum (one finger breadth above the xiphisternum) the operator keeps his arms straight with the heel of one hand resting on the palm of another and depresses the sternum for about 4 cm (or a third of the antero-posterior diameter of the chest) at a rate of 100 compressions per minute. CPR is administered at the rate of two breaths per 15 compressions. If a second person is available, the rate can be adjusted to one breath per 5 compressions.

In trauma victims and patients with suspected massive bleeding, the extent of blood volume loss must be assessed. Pale, ashen skin indicates at least a 30 per cent loss in blood volume. A rapid, thready pulse is an early sign of hypovolaemia. External, severe haemorrhage should be identified and controlled by direct local pressure. The normal blood volume according to the age and a rough guide to assessing extent of blood loss are depicted in Table 2.

A rapid assessment of the neurological status of the patient must be carried out to ascertain the extent of disability. The mnemonic “AVPU” (Alert, responds to vocal stimulus, responds to painful stimulus, unresponsive)¹ may be useful in carrying out a quick assessment of the neurological status. The Glasgow coma scale (Table 2)⁸ can be used subsequently for a more detailed assessment.

The Glasgow coma scale is composed of three parameters: best eye response, best verbal response, best motor response; and is scored between 3 and 15, 3 being the worst, and 15 the best. A score of 13 or higher correlates with a mild brain injury, 9 to 12 is a moderate injury, and 8 or less is suggestive of a severe brain injury.4

In patients with suspected poisoning, gastro-intestinal decontamination and removal of soiled clothing to reduce absorption through the skin must be undertaken¹⁰. If the patient is conscious, induction of emesis by administering syrup of ipaecac (30 ml for adults) can be attempted if the ingested substance is such that it cannot be adsorbed by activated charcoal. Further, stomach wash with a wide bore stomach tube and gastric lavage with activated charcoal can be undertaken. These measures should not be attempted in obtunded or unconscious patients till tracheal intubation with a cuffed endotracheal tube is performed to protect the airway¹⁰.

Patients who sustain multiple injuries or burns must be fully undressed to facilitate a thorough examination. Care must be ensured that the patient is kept warm by covering the patient with blankets.

As the airway, breathing, and circulation are being assessed, resuscitation to achieve adequate tissue perfusion must be initiated concurrently. Vital signs such as the oral temperature, pulse, respiration, arterial oxygen saturation (pulse oximetry), blood pressure, hourly urinary output among others, must be accurately assessed and periodically monitored. In patients with hyperpyrexia, as observed in patients with heat stroke or acute severe falciparum malaria, core temperature measurement with rectal thermometer may be helpful. As per the patient requirement, a nasogastric tube, and a urinary catheter must be inserted.

If breathing is found to be inadequate, 100 per cent oxygen must be administered through a mask and tracheal intubation must be carried out if necessary. If there is no return of spontaneous circulation following the BLS algorithm, the ALS algorithm (Figures 1a and 1b)⁹ should be followed for further resuscitation.

Venous access must be secured by inserting a large bore venous cannula into the most accessible peripheral vein and crystalloid infusion must be started. In the ER setting, valuable time may be lost in inserting a central venous line which may be inserted later after initial stabilisation. In patients with massive haemorrhage, efforts must also be directed towards procuring cross-matched packed red blood cells for transfusion.

Simultaneously, blood samples for relevant laboratory tests need to be taken, and imaging diagnostic modalities must be undertaken. Availability of innovations such as glucometer, portable bed-side ultrasound, echocardiography, and chest radiograph for example, has drastically changed the perspective of ER care in the last decade.

After the patient has been resuscitated and stabilised, secondary evaluation by an experienced ER doctor must be undertaken to ascertain the diagnosis and formulate a plan for the specific management. A detailed history should be elicited from the patient if possible, or from the relatives, and should cover the chronological sequence of events, associated co-morbid illnesses, past medical history, family history, details regarding allergies, among others. In patients with suspected poisoning, history regarding all drugs taken including non-prescription drugs and “over-the-counter-medications” must be noted. Empty containers found in the vicinity of the patient may sometimes be the only clue to the nature of the poisoning in the Indian setting.

A thorough physical examination is most helpful in identifying the aetiological cause and instituting specific treatment. For example, ER teams in India often have to evaluate “unknown, unconscious persons found on the road side” brought by the police. Since no history is available, a thorough physical examination is often the only tool for aetiological diagnosis. Several scoring systems^11–13 are available to predict the outcome of patients in the ER and their help should be taken for assessing the prognosis and formulating a treatment plan.5

Following the secondary survey, the working diagnosis would be evident and measures towards specific treatment of the patient would have to be initiated. Depending on the setting, definitive care includes fracture stabilisation, operative intervention, administration of antidote, initiation of appropriate antibiotic, emergency management of acute myocardial infarction, stroke, among others. The patient should then be transferred under the care of a specialist for further management. The patient should only be transferred if stable, and it is desirable that the patient is shifted with appropriate medical escort.

With advances in the management of life threatening medical and surgical conditions evolving, the perspective of ER management is undergoing a drastic change. Several aspects such as the level of pre-hospital care, effective chain of management, thorough initial assessment and resuscitation, training and skills in BLS and ALS, secondary survey and referral for expert management influence the successful outcome of a patient presenting to the ER.