Introduction to emergency medicine

Scope

Approach to the emergency patientEMSTriage

APPROACH TO THE EMERGENCY PATIENT

extremely challenging environmentavailable and prepared at any time

for any patient with any complaintunfamiliar

Clinical scope of the problem

Anatomic essentials

AirwayBreathingCirculationDisabilityExposure

History

Physical examination

Temperature HR RR BP O2 sat Pain score GCS

Laboratory studies

DTX ECG

Radiologic studies

Bedside ultrasonography

Special patients

PediatricBroselow resuscitation tape

Disposition

ConsultationSerial evaluationAdmission/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 firstAn 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 conversationConsider dangerous outcomes or the

worst-case scenario in every patient.

EMERGENCY MEDICAL SERVICES

extension of emergency medical care into the prehospital setting

รถปฏิ�บั�ติ�การฉุ�กเฉุ�น

Ground transport

http://www.manafeth.com/index.php/en/products/view/Ambulance-Type-I#

Air transport

มาติรฐานอุ�ปกรณ์�ทั่��วไป

อุ�ปกรณ์�ทั่��ใช้�ประกอุบัในพาหนะลำ าเลำ�ยงหร#อุขนส่&ง เพ#�อุ ให�ผู้(�ป)วยได้�ร�บัความส่ะด้วก ส่บัาย

หมอุน พร�อุมปลำอุกหมอุน ผู้�าคลำ�มเติ�ยง ผู้�าห&ม ผู้�าเช้,ด้ติ�วกระด้าษช้ าระ ภาช้นะ อุ�ปกรณ์�เก,บัส่��งข�บัถ&าย เช้&น Bed pan,

Urinal, ถ�งจั�ด้เก,บัเส่มหะหร#อุอุาเจั�ยน น 0าด้#�ม แก�วน 0า แลำะน 0าส่ะอุาด้ส่ าหร�บัช้ าระลำ�าง

อุ�ปกรณ์�ส่ารส่นเทั่ศแลำะการส่#�อุส่าร

Medical Equipment

อุ�ปกรณ์�ทั่างการแพทั่ย�พ#0นฐาน1. อุ�ปกรณ์�ขนย�ายลำ าเลำ�ยง2. อุ�ปกรณ์�เพ#�อุการติรวจัว�น�จัฉุ�ย3. อุ�ปกรณ์�ปฐมพยาบัาลำแลำะทั่ าแผู้ลำ4. อุ�ปกรณ์�ช้&วยช้�ว�ติข�0นพ#0นฐาน

Medical Equipment

อุ�ปกรณ์�ทั่างการแพทั่ย�เฉุพาะด้�าน1. อุ�ปกรณ์�ส่ าหร�บัทั่ าคลำอุด้2. อุ�ปกรณ์�ส่ าหร�บัการช้&วยช้�ว�ติข�0นส่(ง3. อุ�ปกรณ์�ส่ าหร�บัการช้&วยเหลำ#อุทั่��เก��ยวก�บัระบับัทั่างเด้�น

หายใจั4. อุ�ปกรณ์�ส่ าหร�บัการช้&วยเหลำ#อุทั่��เก��ยวก�บักระด้(ก5. ยาหร#อุเวช้ภ�ณ์ฑ์�

Medical Equipment

Medical Equipment

อุ�ปกรณ์�เพ#�อุความปลำอุด้ภ�ยขอุงการปฏิ�บั�ติ�การ

1. อุ�ปกรณ์�ป4อุงก�นตินเอุง2. อุ�ปกรณ์�ป4อุงก�นบัร�เวณ์ทั่��ปฏิ�บั�ติ�งาน3. อุ�ปกรณ์�อุ#�นเพ#�อุช้&วยเหลำ#อุแลำะเพ#�อุความปลำอุด้ภ�ยขอุง

ผู้(�ป)วยฉุ�กเฉุ�น

Manpower

Phases of EMS response

TRIAGE

simplest term: the sorting or prioritizing of items

1º operational objectives: time to see physician

Assigning Triage

"usual presentation" not totally dictated by the presenting

complaintvital signs, PEFR, O2 saturation, pain

scales

Role of Triage Personnel

triage nurse rapid access be in view of the registration and waiting

areas at all timesAccurate: based on

Practical knowledge gained through experience and training.

Correct identification of signs or symptoms. Use of guidelines and triage protocols.

General Triage Guidelines

dynamic processTriage Process: Primary survey vs

Primary Nursing Assessment

General Triage Guidelines

1. All patients should be assessed (at least visually) within 10 minutes of arrival.

2. Full patient assessments should not be done in the triage area

General Triage Guidelines

3. primary survey level IV and V patients that have been sent

to the waiting area

4. The priority for care may change5. Level I, II, patients should be in a

treatment area

The triage assessment

1. Chief complaint2. Subjective3. Objective4. Additional Information:

Allergies Medications

Reassessment

Objectives for time to Nursing reassessment is related to triage level

exceeded the time objective: up triaged

Documentation Standards

1. Date and time of triage assessment.2. Nurse’s name.3. Chief complaint or presenting concerns.4. Limited subjective history: onset of injury/symptoms5. Objective observation.6. Triage Level7. Location in the department.8. Report to treatment nurse.9. Allergies10.Medications11.Diagnostic, first aid measures, therapeutic

interventions.12.Reassessment(s).

Protocols

Emergency Severity Index (ESI©)the Canadian Triage Acuity Scale

(CTAS©)the Australian Triage Scale (ARS©)the Manchester Triage System

(MTS©)

Level I Resuscitation

Conditions that are threats to life or limb (or imminent risk of deterioration) requiring immediate aggressive interventions.

Level II Emergent

Conditions that are a potential threat to life limb or function, requiring rapid medical intervention or delegated acts.

Level II Emergent

Level III Urgent

Conditions that could potentially progress to a serious problem requiring emergency intervention.

Level IV Less Urgent (Semi urgent)

Conditions that related to patient age, distress, or potential for deterioration or complications would benefit from intervention or reassurance within 1-2 hours.

Level V Non Urgent

Conditions that may be acute but non-urgent as well as conditions which may be part of a chronic problem with or without evidence of deterioration.

Australian triage scale

Manchester triage scale

NUH triage

NUH triage

NUH triage

Reference

An introduction to clinical emergency medicine – 2nd ed.

มาติรฐานแลำะหลำ�กเกณ์ฑ์�เก��ยวก�บัระบับัการแพทั่ย� ฉุ�กเฉุ�น พ.ศ. ๒๕๕๒

ESI, 2012 editionCTAS, 2008 editionATSMTS

Take home message

available and prepared at any time for any patient with any complaint

Always address life-threats firstEmergency department: EMS + ERTriage: sorting or prioritizing

ANY QUESTIONS?

THANK YOU