Emergency Protocol for the Management of the Unconscious or Critically Ill Patient

A Comprehensive Protocol for the Management of Critically Ill Patients in the Emergency Department and Intensive Care Unit

By Lin Ru Wu (alias Lim Ju Boo)

Abstract:

Critically ill and unconscious patients require immediate and structured care to prevent morbidity and mortality. This paper presents an evidence-based, multidisciplinary management protocol for doctors working in Emergency Departments (EDs) and Intensive Care Units (ICUs), structured around the widely accepted ABCDE approach, and addressing organ support, nutritional care, infection control, medication review, and coordinated communication. This protocol complements the perspectives outlined in "Beyond the Pill: A Critical Review of Pharmacology, Chronic Disease, and the Path to Root-Cause Healing" (Lim, 2025).

1. Introduction:

Effective management of the unconscious or critically ill patient is vital to improving outcomes. A structured approach helps prevent critical oversights, allows rapid stabilization, and facilitates multidisciplinary teamwork. Evidence supports that implementing structured clinical protocols in emergency and critical care improves survival and reduces errors (Resuscitation Council UK, 2021; NICE Guidelines, 2022).

2. Initial Assessment and Resuscitation: The ABCDE Principle

A - Airway Management: 

Airway patency is a priority. Obstruction from secretions, blood, or the tongue must be cleared. Endotracheal intubation should be performed when necessary using appropriately sized tubes (7.0–7.5 mm for females, 8.0–8.5 mm for males) and confirmed with capnography (Griesdale et al., 2012). Cuff pressures must be maintained between 20–30 cm H₂O to prevent tracheal injury (Sole et al., 2011). Suctioning should be based on clinical indication, with regular evaluation of secretion characteristics for early infection signs.

B - Breathing:  

Breathing is evaluated through inspection, auscultation, and pulse oximetry. Hypoventilation necessitates bag-valve-mask ventilation or mechanical support. Oxygen is administered generously, aiming for SpO₂ > 94% (WHO, 2020). Elevating the head of the bed to 30 degrees improves oxygenation and prevents aspiration (Drakulovic et al., 1999).

C - Circulation: 

Cardiovascular assessment includes blood pressure, heart rate, and ECG monitoring. Serum lactate serves as a marker of tissue perfusion and shock (Jansen et al., 2010). IV access is established via two large-bore cannulas, with fluid resuscitation tailored to volume status. Focused cardiac ultrasound (FOCUS) can assist in detecting cardiac tamponade, ventricular dysfunction, or hypovolemia (Kirkpatrick et al., 2004).

D - Disability:  

Neurological status is assessed via the Glasgow Coma Scale (GCS). Pupils, tone, reflexes, and limb movement guide further neurological evaluation. Blood glucose must be checked immediately, with hyper- or hypoglycemia treated promptly. Imaging (CT/MRI) is indicated for suspected stroke, trauma, or seizures (Adams et al., 2007).

E - Exposure and Environment: 

The patient must be undressed for thorough examination. Pressure points, skin integrity, surgical sites, and temperature must be evaluated. Hypo- or hyperthermia should be corrected, as both contribute to increased mortality (Mackowiak et al., 1992).

3. Internal Organ Support and Nutritional Management:

Electrolyte and Acid-Base Balance Daily monitoring and correction of electrolytes (Na⁺, K⁺, Ca²⁺, Mg²⁺, PO₄³⁻, Cl⁻) are essential. Arterial blood gas (ABG) analysis guides management of acid-base disorders, with prompt intervention to prevent metabolic complications (Vincent et al., 2005).

Fluid Balance: 

Fluid input and output should be charted meticulously. Urinary catheterization aids hourly monitoring. Cumulative balance helps assess volume overload or depletion (Cecconi et al., 2014). Fluid targets must be individualized based on perfusion status and clinical needs.

Nutrition:  Enteral feeding should begin within 24–48 hours once hemodynamic stability is achieved (ESPEN Guidelines, 2019). A dietitian should calculate daily caloric and protein requirements to avoid catabolism and support immune function.

4. Gastrointestinal Care: 

Prophylaxis for stress ulcers is initiated using proton pump inhibitors (PPIs) or H₂ blockers (Cook et al., 1998). Bowel movements should be monitored, with constipation addressed via oral laxatives or prokinetics. Nasogastric tubes are indicated for feeding or decompression, with measures taken to reduce aspiration risk.

5. Infection Surveillance and Control:

Daily review of WBC count, CRP, procalcitonin, and temperature trends is necessary. All invasive lines, catheters, and tubes must be reviewed and removed when no longer required (CDC Guidelines, 2020). Wound inspection and early identification of pressure injuries are vital in preventing sepsis (Sullivan et al., 2013).

6. Medication Management and Prophylaxis: 

All medications should be reviewed daily. Chronic medications may be reinstated as appropriate. Intravenous drugs should be converted to oral when feasible. Prophylaxis against deep vein thrombosis using unfractionated or low-molecular-weight heparin is recommended (Geerts et al., 2008). Pain is managed using analgesics based on validated scoring systems.

7. Multidisciplinary Care and Family Communication: 

Physiotherapy is essential for respiratory care and limb mobilization. Passive exercises prevent joint contractures and venous stasis (Perme et al., 2012). Regular input from neurology, nephrology, surgery, and other specialties is essential. Family members should be informed daily, with discussions on prognosis and care preferences initiated early where necessary.

8. Conclusion: 

The care of the critically ill requires a structured, systematic, and compassionate approach. This comprehensive protocol ensures life-saving interventions are timely and evidence-based while incorporating nutritional, psychological, and rehabilitative aspects. The art of medicine lies not just in clinical acumen but in coordinating care that preserves dignity, ensures safety, and promotes recovery.

References:

1. Resuscitation Council UK. (2021). ABCDE approach.

2. NICE Guidelines. (2022). Acute illness in adults in hospital: recognising and responding to deterioration.

3. Griesdale DE et al. (2012). Endotracheal intubation in the ICU. Intensive Care Med.

4. Sole ML et al. (2011). Airway management and cuff pressure. Am J Crit Care.

5.WHO. (2020). Clinical management of severe acute respiratory infection.

6. Drakulovic MB et al. (1999). Semi-recumbent positioning to prevent pneumonia. Lancet.

7. Jansen TC et al. (2010). Lactate monitoring in critically ill patients. Am J Respir Crit Care Med.

8. Kirkpatrick AW et al. (2004). Focused Assessment with Sonography for Trauma (FAST). J Trauma.

9. Adams HP et al. (2007). Stroke management guidelines. Stroke.

10. Mackowiak PA et al. (1992). Fever and host responses. Ann Intern Med.

11. Vincent JL et al. (2005). Acid-base disorders in the ICU. Crit Care.

12. Cecconi M et al. (2014). Fluid management in critically ill patients. Lancet.

13. ESPEN Guidelines. (2019). Clinical nutrition in the ICU.

14. Cook DJ et al. (1998). Stress ulcer prophylaxis in the ICU. N Engl J Med.

15. CDC. (2020). Guidelines for prevention of catheter-related infections.

16. Sullivan DH et al. (2013). Pressure ulcers and infection. Adv Skin Wound Care.

17. Geerts WH et al. (2008). Prevention of venous thromboembolism. Chest.

18. Perme C et al. (2012). Early mobility in the ICU. Crit Care Nurse.

Appendices: 

1. Checklist for Daily Critical Care Rounds
2. ABCDE Protocol Summary
Nutritional and Fluid Monitoring Templates