Approaching and Managing Emergencies Dr. Gwen Hollaar University of Calgary.

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 Assess – C: Circulation Resuscitate– D: Disability Monitor– E: Exposure

• Secondary Survey

• Continue to 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

Breathing• Assess

– 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

Punctured lung from rib fracture or penetrating injury to chest causes air &/or blood in space between lung and chest pleura --> lung collapses

Normal lungs: No space between lung pleura and chest wall pleura

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

Circulation• Assess

– 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

Mental state Normal Anxious Anxious/Confused Confused/Drowsy

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

Resp rate <10 10-14 15-20 21-30 >30

Heart rate <40 40-50 51-100 101-110 111-130 >130

BP systolic <70 71-80 81-100 101-199 >200

CNS SC A V P U

Temp <35 35-38 38-39 >39

Urine output(ml/kg/hr)

0 < 0.5

SC - Sudden confusion / A - Alert / V - responds to voice / P - responds to pain / U - Unresponsive

Normal Vital Signs in Children

AGE HR(per min)

BPsystolic

0 - 1 yr 100 - 160 >60

1- 3 yr 90 - 150 >70

3 - 6 yr 80 - 140 >75

AGE RR(per min)

< 2 months 30 - 60

2 - 11 months

20 - 50

1 - 5 yr 20 - 40

Heart Rate and Blood Pressure Respiratory Rate

Children should make > 1 ml/ kg/ hr of urine

Summary

• Primary Survey– A: Airway – B: Breathing Assess – C: Circulation Resuscitate– D: Disability Monitor– E: Exposure

• Secondary Survey

• Continue to monitor / Arrange

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