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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 – – – – – 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