Approach to the emergency patient

Approach to the emergency patientPaleerat Jariyakanjana, MDEmergency Physician, Faculty of Medicine,Naresuan University24 Oct 2014

extremely challenging environment available and prepared at any time for

any patient with any complaint unfamiliar

Clinical scope of the problem

Primary survey

Airway Breathing Circulation Disability Exposure

History

Physical examination

T HR RR BP O2 sat Pain score GCS

Laboratory studies

DTX ECG

Radiologic studies

Bedside ultrasonography

Special patients

Pediatric Broselow resuscitation tape

Disposition

Consultation Serial evaluation Admission/discharge

Admission/discharge

discharge instructions1) what to do

2) what not to do

3) when (and where) to follow-up

4) reasons to return to the ED

Pearls, pitfalls and myths

Always address life-threats first An exact diagnosis is not always

possible in EM, and not always necessary.

elderly patients: uncommon presentations

Never rush a patient out of the ED with a condition that may recur

Pearls, pitfalls and myths

Think about abuse or neglect in every case.

Document appropriate findings in the medical record clearly. consultant’s name, service, time you spoke, and brief

summary of the conversation Consider dangerous outcomes or the

worst-case scenario in every patient.

ATLS 9TH EDITION

Initial assessment

Preparation Triage Primary survey (ABCDEs) Resuscitation Adjuncts to primary survey and resuscitation Consideration of the need for patient transfer Secondary survey (head-to-toe evaluation and

patient history) Adjuncts to the secondary survey Continued postresuscitation monitoring and

reevaluation Definitive care

Primary survey

Airway maintenance with cervical spine protection

Breathing and ventilation Circulation with hemorrhage control Disability Exposure/Environmental control

What is a quick, simple way to assess apatient in 10 seconds?

asking the patient for his or her name, and asking what happened no major airway compromise (ability to speak clearly) breathing is not severely compromised (ability to

generate air movement to permit speech) no major decrease in level of consciousness (alert

enough to describe what happened) prioritized sequence

Airway maintenance with cervical spine protection

able to communicate verbally patent signs of airway obstruction

Secretion or blood per mouth/nose Stridor inspection for foreign bodies facial, mandibular, or tracheal/laryngeal fractures severe head injuries definitive airway

Airway maintenance with cervical spine protection

traumatic incident loss of stability of the cervical spine should be

assumed protection of the patient’s spinal cord with appropriate

immobilization devices Evaluation and diagnosis of specific

spinal injury, including imaging, should be done later.

Airway maintenance with cervical spine protection

Lateral film: 85% of all injuries Assume a cervical spine injury

blunt multisystem trauma, especially those with an altered level of consciousness or a blunt injury above the clavicle

Inline Immobilization Techniques

Breathing and ventilation

neck and chest assess jugular venous distention, position of the

trachea, and chest wall excursion Auscultation, visual inspection and

palpation, percussion Injuries

tension pneumothorax, flail chest with pulmonary contusion, massive hemothorax, and open pneumothorax

Tension Pneumothorax

hyperresonant note on percussion

deviated trachea

absent breath sounds over the affected hemithorax

http://www.trauma.org/archive/thoracic/CHESTtension.html

Tension Pneumothorax

Immediate decompression rapidly inserting a

large-caliber needle into the 2nd intercostal space in the midclavicular line of the affected hemithorax

Open Pneumothorax (Sucking Chest Wound)

Air tends to follow the path of least resistance

opening in the chest wall: ≥2/3 diameter of the trachea

3-sides occlusive dressing Any occlusive dressing (e.g., plastic

wrap or petrolatum gauze) may be used

Open Pneumothorax (Sucking Chest Wound)

Flail Chest and Pulmonary Contusion

≥2 adjacent ribs fractured in ≥2 places paradoxical motion pulmonary contusion Adequate oxygenation, administer fluids

judiciously, and provide analgesia

Flail Chest and Pulmonary Contusion

http://en.wikipedia.org/wiki/Flail_chest

Flail Chest and Pulmonary Contusion

http://watilearned2day.blogspot.com/2013/08/question-of-day-flail-chest.html

Massive Hemothorax

rapid accumulation of >1500 mL of blood or ≥1/3 of the patient’s blood volume in the chest cavity

continuing blood loss (200 mL/hr for 2-4 hours

Breathing and ventilation

Simple pneumothorax or hemothorax, fractured ribs, and pulmonary contusion compromise ventilation to a lesser degree usually identified during the secondary survey

Circulation with hemorrhage control

Blood Volume and Cardiac Output level of consciousness skin color pulse

Circulation with hemorrhage control

Bleeding external or internal External hemorrhage

direct manual pressure on the wound Tourniquets

• effective in massive exsanguination• risk of ischemic injury • only be used when direct pressure is not effective

Hemostats: damage to nerves and veins

Circulation with hemorrhage control

Bleeding major areas of internal hemorrhage

chest, abdomen, retroperitoneum, pelvis, and long bones

identified by physical examination imaging (e.g., chest x-ray, pelvic x-ray, or focused

assessment sonography in trauma [FAST]) Management

chest decompression, pelvic binders, splint application, and surgical intervention

Focused Assessment Sonography in Trauma [FAST]

http://blog.afravietmur.com/post/2011/07/28/D%C3%A9veloppement-de-l-%C3%A9chographie-aux-urgences

Disability (neurologic evaluation)

level of consciousness pupillary size and reaction lateralizing signs spinal cord injury level

Disability (neurologic evaluation)

Exposure and environmental control

completely undressed Keep warm

Warm blankets or an external warming device Warm Intravenous fluids and a warm environment

(i.e., room temperature)

Resuscitation

Airway Breathing, Ventilation, and Oxygenation Circulation and Hemorrhage Control

Airway

Suction: rigid suction

jaw-thrust or chin-lift maneuver

oropharyngeal airway: unconscious and has no gag reflex

Airway

definitive airway protection of the cervical spine

Breathing, ventilation, and oxygenation

supplemental oxygen: mask-reservoir device ≥11 L/min

tension pneumothorax chest decompression Intercostal drainage (ICD)

Open pneumothorax occlusive dressing ICD

Massive hemothorax: ICD

Circulation and hemorrhage control

2 large-caliber IV catheters, upper-extremity peripheral IV access

Warmed crystalloids, bolus of 1-2 L of isotonic solution

If the patient is unresponsive to initial crystalloid therapy, blood transfusion should be given.

baseline hematologic studies + G/M UPT Blood gases and/or lactate level: assess

shock

Adjuncts to primary survey and resuscitation

Electrocardiographic monitoring urinary and gastric catheters other monitoring

ventilatory rate, arterial blood gas (ABG) levels, pulse oximetry, blood pressure

x-ray examinations

Urinary and gastric catheters

Urinary Catheters C/I in urethral injury

Blood at the urethral meatus Perineal ecchymosis High-riding or nonpalpable prostate

Gastric Catheters C/I: cribriform plate fracture

X-ray examinations anddiagnostic studies

AP chest AP pelvis FAST Diagnostic peritoneal lavage (DPL)

Consider Need for Patient Transfer

primary survey and resuscitation phase enough information

Diagnosis & consult

Secondary Survey

History Physical examination: head-to-toe

evaluation

History

Allergies Medications currently used Past illnesses/Pregnancy Last meal Events/Environment related to the injury

Adjuncts to the Secondary Survey

Specialized diagnostic tests Additional x-ray examinations of the spine and

extremities CT scans of the head, chest, abdomen, and spine Contrast urography and angiography transesophageal ultrasound Bronchoscopy Esophagoscopy other diagnosticprocedures

Reevaluation

Continuous monitoring of vital signs and urinary output

relief of severe pain Tetanus toxoid, antibiotic

Take home message

Primary survey (ABCDEs) Airway Breathing Circulation Disability Exposure

Reference

An introduction to clinical emergency medicine – 2nd ed.

ATLS 9th Student Manual

ANY QUESTIONS?