Download Approaching and Managing Emergencies

Approaching and Managing
Emergencies
Dr. Gwen Hollaar
University of Calgary
Patient: Khampanh
• 36 year old male
• Motorbike accident
• Complains of chest pain and shortness of
breath
• RR 35 / PR 120 / BP 110/75 / Temp 37
• Is this an emergency? / What will you do?
Patient: Phoutong
• 29 year old woman (G5,P4) who
delivered baby at home 4 hours ago
• She continues to bleed from her vagina
• She is drowsy and pale
• RR 25 / PR 140 / BP 80/40 / Temp 36.5
• Is this an emergency? / What will you
do?
Patient: Noi
•
•
•
•
11 month old girl
Has been sick for 3 days
Agitated and restless
RR 50 / HR 165 / Temp 38
• Is this an emergency? / What will you do?
Recognizing an Emergency
• Many patients who come to ER, are not
acutely ill
• Important to recognize when a patient has a
serious or acute problem
• Patients die unnecessarily when a true
emergency is not recognized
• Need to have systematic approach so that
you can be quick and complete in your
assessment and management of patients
Common Mistakes in
Emergencies
• Patient assessment is not thorough
• Symptoms and signs of a serious illness
are not recognized
• Appropriate and urgent care is not
provided
• Patient is not regularly monitored
General Approach
• Primary Survey
–
–
–
–
–
A: Airway
B: Breathing
C: Circulation
D: Disability
E: Exposure
• Secondary Survey
• Continue to monitor
Assess
Resuscitate
Monitor
Airway
• Assess
– Can they answer “Are you okay?”
• If patient can answer, airway is okay
– If no answer
• Inspect:
– Mouth clear
– Look for chest movement
• Feel:
– Feel for air movement at mouth
• Listen:
– Listen for air movement at mouth
Airway
• WARNING SIGNS
– Decreased consciousness
– Stridor
– Voice change
– Tongue swelling
– Burn around face
Airway
• Resuscitate
– Jaw lift
– Insert oropharyngeal airway
– Bag patient or intubate if patient is
unconscious
– If patient is seriously ill or injured, give O2
• Assess
Breathing
– Inspect:
•
•
•
•
Respiratory rate
Colour of lips and fingers
Symmetry of chest movement
Use of accessory muscles
– Palpate:
• Subcutanous emphysema / Tracheal deviation
• Symmetry of chest movement
– Percuss:
• Hyper-resonant (pneumothorax)
• Dull (pulmonary edema / effusion / pneumonia/
hemothorax)
– Auscultate:
• Absent sounds / Abnormal sounds / Symmetry of sound
Breathing
• WARNING SIGNS
–
–
–
–
–
–
–
Decreased consciousness
Cyanosis
Tracheal deviation / Subcutaneous emphysema
Resp rate <10 or >30
Unable to count to 5 in single breath
Asymmetric chest movement
O2 saturation < 90%
Breathing
• Resuscitate
• Severe bronchospasm / Severe wheezing
– Bronchodilator (salbutamol)
• Tension pneumothorax
– Needle thoracentesis
Chest Cavity
Normal lungs: No space
between lung pleura and
chest wall pleura
Punctured lung from rib
fracture or penetrating
injury to chest causes air
&/or blood in space
between lung and chest
pleura --> lung collapses
Clinical Signs
Pneumothorax
Inspection
Possible chest bruising
Tracheal deviation (if tension pneumothorax)
Palpation
Subcutaneous emphysema
Possible tenderness or crepitus over chest wall
Percussion
Hyperresonant
Auscultation
Absent breath sounds
Tension Pneumothorax
• If patient is in acute respiratory distress
and has subcutaneous emphysema and
deviated trachea to contralateral side
– To immediately relieve the tension, insert
needle into 2nd intercostal space in mid
clavicular line
– Chest tube can be put in later
Breathing
• Monitor
– Resp rate
– Resp effort
– O2 saturation (if available) / Cyanosis
• Assess
Circulation
– Inspect:
•
•
•
•
Colour (pale / cyanosis)
Temperature of skin
Dilated neck veins
Dry mucous membranes
– Palpate:
• Pulse rate and character (compare peripheral and central
pulse)
• Capillary refill / Skin turgor
• Character and location of cardiac apex beat
– Auscultate:
• BP
• Heart sounds / Extra heart sounds / Murmors
Circulation
• WARNING SIGNS
– Decreased consciousness
– Very pale / Mottled skin
– Much sweating
– Systolic BP < 90
– PR > 130
– Narrowed pulse pressure
– Abnormal heart rhythm and hypotension
Circulation
• Pulse Pressure
– Difference between systolic and diastolic pressure
• BP: 120/80 = pulse pressure is 120 - 80 = 40
– Young patients can compensate to maintain good
cardiac output for quite awhile even when they are
going into shock by:
– Increasing HR
– Maintaining strong ventricular contractions
– Vasoconstriction
– Narrowed pulse pressure is worrisome
• Patient maintains normal systolic pressure
• Patient’s diastolic pressure begins to go up
– Be watchful for narrowed pulse pressure because
patient may be tachycardic and have normal
systolic BP, but suddenly go into shock
Circulation
• Cardiac Output = stroke volume X heart rate
• Types of Shock
– Hypovolemic Shock
• Loss of blood & plasma volume
– Cardiogenic Shock
• Poor ventricular function
– Distributive
• Septic Shock
– Vasodilation and increased vascular permeability (plasma
volume loss)
• Anaphylactic Shock
– Vasodilation
• Neurogenic Shock
– Loss of vasomotor control (no vasoconstriction)
Circulation
• Common causes of hypovolemic shock
– Blood Loss
• Pregnancy
• Trauma
• Gastrointestinal bleeding
– Plasma Loss
•
•
•
•
Diarrhea and vomiting
Burns
Diabetic ketoacidosis
Pancreatitis
– “Apparent loss”: Decrease preload (amount of blood
returning to heart)
• Drugs: Diuretics, opiates, Nitrates
Categories of Hypovolemic Shock (ADULT)
1
2
3
4
Blood
loss(litre)
< 0.75
0.75 - 1.5
1.5- 2.0
> 2.0
Blood loss (%
blood volume)
< 15%
15 - 30%
30 - 40%
> 40%
Resp rate
14-20
20 - 30
30 - 40
> 35 or low
Heart rate
< 100
> 100
> 120
>140 or low
Systolic BP
Normal
Normal
Decreased
Decreased +
Diastolic BP
Normal
Raised
Decreased
Decreased +
Pulse
Pressure
Normal
Decreased
Decreased
Decreased
Capillary refill
Normal
Delayed
Delayed
Delayed
Urine output
(ml/hr)
>30
20 - 30
5 - 15
Almost none
Anxious/Confused
Confused/Drowsy
Mental state
Circulation
• Resuscitate
– Hypovolemic shock
•
•
•
•
Large bore IV (16 or 18 gauge) / Start two IV’s
Give 2 litres of isotonic fluid quickly
Consider giving blood
Control hemorrhage / Call surgery
– Septic shock
• IV isotonic fluid bolus & IV antibiotics (broad spectrum)
– Anaphylactic shock
• IV isotonic fluid bolus & adrenaline
– Cardiogenic shock
• Drugs for dysrhythmias / Drugs to reduce afterload or
pulmonary edema
Circulation
• Monitor
– Pulse rate / BP
– Urine output
– O2 saturation (if available)
Disability
• Assess
– Level of Consciousness
• Alert / Responds to voice / Responds to pain / No
response
• Glasgow coma scale
– Pupils
• Dilated / Equal / Reactive to light
– Posture
• Flaccid
• Flexed arms / Extended legs (decorticate)
• Extended arms / Extended legs (decerebrate)
Disability
• WARNING SIGNS
– GCS < 8 (patient not able to protect
airway)
– Deteriorating level of consciousness
– Meningismus
– Persistent seizure
– Hypoglycemia (presents as decreased
level of consciousness)
Disability
• Resuscitate
– Protect airway / Administer O2
– If hypoglycemic, give glucose
– If persistent seizure, give IV
benzodiazepam
Disability
• Monitor
– GCS or level of consciousness
– Glucose
Exposure
• Look at the entire body
– Site of bleeding
– Purpura (severe sepsis)
– Rashes (anaphylaxis)
Complete Patient Assessment
• History
• Secondary survey
–
–
–
–
–
Face and neck
Chest
Abdomen / Genitalia
MSK / CNS
Skin
• Continue to monitor / Arrange transport
Monitoring
• Regular and ongoing monitoring is very
important
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–
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–
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Respiratory rate
Pulse rate
Blood pressure
Temperature
Urine output
• Minimum urine output in adult is 0.5 ml/kg/hr
– Level of consciousness (i.e. Glasgow coma scale)
Early Warning Scoring System (Adult)
Patient with a score of 3 in any one area or a total score of 4 or more
needs immediate assessment / resuscitation / close monitoring
SCORE
3
2
1
0
1
2
3
10-14
15-20
21-30
>30
101-110
111-130
>130
Resp rate
<10
Heart rate
<40
40-50
51-100
71-80
81-100
101-199
SC
A
V
P
35-38
38-39
>39
BP systolic
<70
CNS
<35
Temp
Urine output
(ml/kg/hr)
0
>200
U
< 0.5
SC - Sudden confusion / A - Alert / V - responds to voice / P - responds to pain / U - Unresponsive
Normal Vital Signs in Children
Heart Rate and Blood Pressure
AGE
Respiratory Rate
HR
BP
(per min)
systolic
0 - 1 yr
100 - 160
>60
< 2 months
30 - 60
1- 3 yr
90 - 150
>70
2 - 11
months
20 - 50
3 - 6 yr
80 - 140
>75
1 - 5 yr
20 - 40
AGE
RR
(per min)
Children should make > 1 ml/ kg/ hr of urine
Summary
• Primary Survey
–
–
–
–
–
A: Airway
B: Breathing
C: Circulation
D: Disability
E: Exposure
• Secondary Survey
• Continue to monitor / Arrange
Assess
Resuscitate
Monitor
Patient: Khampanh
• 36 year old male
• Motorbike accident
• Complains of chest pain and shortness of
breath
• RR 35 / PR 120 / BP 110/85 / Temp 37
• Is this an emergency? / What will you do?
Patient: Khampanh
• Airway: okay
• Breathing:
–
–
–
–
Bruising over right chest
Subcutaneous emphysema over right chest
Tracheal deviation to left
Crepitus on palpation of chest
• Circulation:
– Normal colour and temp
– Pulses equal, normal capillary refill
– Tachycardic, decreased pulse pressure, normal BP
Patient: Phoutong
• 29 year old woman (G5,P4) who
delivered baby at home 4 hours ago
• She continues to bleed from her vagina
• She is drowsy and pale
• RR 25 / PR 140 / BP 80/40 / Temp 36.5
• Is this an emergency? / What will you
do?
Patient: Phoutong
• Airway:
– Assess / Resuscitate / Monitor
• Breathing:
– Assess / Resuscitate / Monitor
• Circulation:
– Assess / Resuscitate / Monitor
Questions