Approach to the emergency patient
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Transcript of 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?