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

2. 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?

3. 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?

4. 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?

5. 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

6. 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

7. General Approach Primary Survey –A: Airway –B: BreathingAssess –C: CirculationResuscitate –D: DisabilityMonitor –E: Exposure Secondary Survey Continue to monitor

8. 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

9. Airway WARNING SIGNS –Decreased consciousness –Stridor –Voice change –Tongue swelling –Burn around face

10. Airway Resuscitate –Jaw lift –Insert oropharyngeal airway –Bag patient or intubate if patient is unconscious –If patient is seriously ill or injured, give O2

11. 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

12. Breathing WARNING SIGNS –Decreased consciousness –Cyanosis –Tracheal deviation / Subcutaneous emphysema –Resp rate 30 –Unable to count to 5 in single breath –Asymmetric chest movement –O2 saturation < 90%

13. Breathing Resuscitate Severe bronchospasm / Severe wheezing –Bronchodilator (salbutamol) Tension pneumothorax –Needle thoracentesis

14. 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

15. Clinical Signs Pneumothorax InspectionPossible chest bruising Tracheal deviation (if tension pneumothorax) PalpationSubcutaneous emphysema Possible tenderness or crepitus over chest wall PercussionHyperresonant AuscultationAbsent breath sounds

16. 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

17. Breathing Monitor –Resp rate –Resp effort –O2 saturation (if available) / Cyanosis

18. 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

19. Circulation WARNING SIGNS –Decreased consciousness –Very pale / Mottled skin –Much sweating –Systolic BP < 90 –PR > 130 –Narrowed pulse pressure –Abnormal heart rhythm and hypotension

20. 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

21. 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)

22. 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

23. Categories of Hypovolemic Shock (ADULT) 1234 Blood loss(litre) < 0.750.75 - 1.51.5- 2.0> 2.0 Blood loss (% blood volume) < 15%15 - 30%30 - 40%> 40% Resp rate 14-2020 - 3030 - 40> 35 or low Heart rate < 100> 100> 120>140 or low Systolic BP Normal DecreasedDecreased + Diastolic BP NormalRaisedDecreasedDecreased + Pulse Pressure NormalDecreased Capillary refill NormalDelayed Urine output (ml/hr) >3020 - 305 - 15Almost none Mental state NormalAnxious Anxious/ConfusedConfused/Drowsy

24. 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

25. Circulation Monitor –Pulse rate / BP –Urine output –O2 saturation (if available)

26. 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)

27. 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)

28. Disability Resuscitate –Protect airway / Administer O2 –If hypoglycemic, give glucose –If persistent seizure, give IV benzodiazepam

29. Disability Monitor –GCS or level of consciousness –Glucose

30. Exposure Look at the entire body –Site of bleeding –Purpura (severe sepsis) –Rashes (anaphylaxis)

31. Complete Patient Assessment History Secondary survey –Face and neck –Chest –Abdomen / Genitalia –MSK / CNS –Skin Continue to monitor / Arrange transport

32. 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)

33. 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 SCORE3210123 Resp rate <1010-1415-2021-30>30 Heart rate <4040-5051-100101-110111-130>130 BP systolic <7071-8081-100101-199>200 CNS SCAVPU Temp <3535-3838-39>39 Urine output (ml/kg/hr) 0< 0.5 SC - Sudden confusion / A - Alert / V - responds to voice / P - responds to pain / U - Unresponsive

34. Normal Vital Signs in Children AGEHR (per min) BP systolic 0 - 1 yr100 - 160>60 1- 3 yr90 - 150>70 3 - 6 yr80 - 140>75 AGERR (per min) < 2 months30 - 60 2 - 11 months 20 - 50 1 - 5 yr20 - 40 Heart Rate and Blood Pressure Respiratory Rate Children should make > 1 ml/ kg/ hr of urine

35. Summary Primary Survey –A: Airway –B: BreathingAssess –C: CirculationResuscitate –D: DisabilityMonitor –E: Exposure Secondary Survey Continue to monitor / Arrange

36. 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?

37. 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

38. 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?

39. Patient: Phoutong Airway: –Assess / Resuscitate / Monitor Breathing: –Assess / Resuscitate / Monitor Circulation: –Assess / Resuscitate / Monitor

40. Questions