Assessment of patient in Emergency room .ppt

Assessment of patient in ER - includes - prealert info and triaging of patients; initial approach of patient in A&E ; leading presentations and deadly diagnosis of A&E; commonly missed diagnosis in A&E ; making good clinical decisions

1. Approach to patient in ER DR.ARUNKUMAR SETHURAMAN M.D(EM-India), MRCEM(UK), FRCEM, PG DIP.USG, Fellowship in Echo & Intensive care medicine A&E REGISTRAR FAIRFIELD GENERAL HOSPITAL, Bury

2. Objectives of my talk Pre-alert info & Triaging of patients Initial approach of patient in A&E Leading presentations & deadly DD’s of A&E Commonly Missed diagnosis in A&E Making good clinical decisions

3. How does the patient inflow happens in ED ?

4. Pathways for patients inflow into ED Self referral, NHS 111 or primary care or ambulance Directing patients to appropriate services prior to clinical assessment Streaming – streamed to co-located/specialist service or primary care, ophthalmology or offsite services eg : simple & complex see & treat; senior doctor triage(SDT); Rapid assessment & treatment(RAT); Early senior assessment(ESA)

5. Patient inflow into ED

6. PRE - ALERT BY AMBULANCE TEAM A - Age and sex of the injured person T - Time of incident M - Mechanism of injury I - Injuries suspected S - Signs, including vital signs and GCS T - Treatment so far E - Estimated time of arrival (ETA) at the emergency department R - Requirements on arrival Preparation of team/specialist Need of other interventions ? Red phone call ATMISTER What’s the benefit of pre-alert ?

7. Manchester triage system NATIONAL TRIAGE SCALE COLOUR TIME TO BE SEEN BY DOCTOR IMMEDIATE RED IMMEDIATELY 2.VERY URGENT ORANGE WITHIN 5-10MTS 3.URGENT YELLOW WITHIN 1 HOUR 4.STANDARD GREEN WITHIN 2 HOURS 5.NON URGENT BLUE WITHIN 3 HOURS

8. Manchester triage system

9. How would you prioritise ? 1. 65yr old male presenting with stridor & breathing difficulty for last 24 hour ? 2. 52yr old cough with expectoration,breathlessness and hypoxic spo2-92% 3. 28yr old presenting after a fall, injured his ankle – ankle appears deformed, dislocated and discolouration of foot 4. 24yr old presenting with extreme agitation, tachycardic, sweating, tremors under the influence of alcohol & possible recreational drug abuse. 5. 72 year old presenting with sudden onset epigastric pain, extremely pale but his vitals are normal except borderline BP-96/60 6. 30yr/M presenting with left side chest pain for 4 days with normal vital signs and normal ECG ? Red Red Red

10. Early warning score - NEWS2 Identification of unwell patient Not to be used in isolation Special population : obstetric early warning score & paediatric early warning score Not beneficial for critically ill patients who are receiving treatment

11. VITAL PARAMETERS Do you know the normal & abnormal range of our vital parameters 1.Temperature ? 2.Pulse rate ? 3.Blood pressure ? 4.Respiratory rate ? 5.SPO2 ? 6.Blood sugar ? 7.Urine output ? 8.Pupils ? 9.Conscious level ?   Normal Lower limit Upper limit TEMPERATURE 97.8 – 99 F <95 F >104 F PULSE RATE 60-100 beats/mt <60/mt >100/mt BLOOD PRESSURE 120/80 mm hg 90/60mmhg 140/90 mmhg RESPIRATORY RATE 12 – 16 Breaths/ mt <10/ mt >30/mt SPO 2 >95% <95%   BLOOD SUGAR 80-120mg/dl <70mg/dl >200mg/dl URINE OUTPUT >1ml/kg/hour <1ml/kg/hour >2ml/kg/hour PUPILS 2mm - 5mm <2mm >5mm CONSCIOUS LEVEL - AVPU SCALE ALERT - TO SPEECH - TO PAIN - UNRESPONSIVE

12. ER ARRIVAL APPEARANCE OF PATIENT Alert/ Irritable/Unconscious Pale /cyanotic Stridor/Tachypnoeic /dyspnoeic Cachexic / obese Toxic / normal Diaphoretic / Jaundiced External bleeding etc

13. STRUCTURED APPROACH

14. Primary survey - ABCDE approach Airway Breathing Circulation Disability Exposure

15. Airway - causes & assessment CAUSES: 1.CNS depression 2. Blood 3. Vomit 4. Foreign body 5. Trauma ASSESSMENT Talking - patent airway Choking, Stridor, Noisy breathing, wheeze, gurgling Shortness of breath, Difficulty breathing, distressed See-saw respiratory pattern, accessory muscles use

16. What would you do next ? High flow Oxygen @ 15lts/ mt Suction Head Tilt and chin lift Jaw thrust if C-spine injury suspected Oro-pharyngeal Airway Naso -pharyngeal Airway I-gel, Laryngeal Mask Airway (LMA) Endotracheal tube

17. INSPECTION: Respiratory Rate Chest expansion Working accessory muscle Deformity PALPATION: • Trachea position,Tenderness • Surgical emphysema • Crepitus PERCUSSION: • Dullness or hyper- resonance AUSCULTATION: For breath sounds and equality BREATHING – What information have you got? TREATMENT Open Airway Oxygen Support (target 94-98%; 88-92% in COPD) Treat Underlying Problem: Bronchodilator Nebulizer is wheezy chest Needle Thoracocentesis if Tension Pneumothorax Assisted Ventilation – BMV, NIV, intubation

18. What can you diagnose with ? Inspection ? Palpation ? Percussion ? Auscultation ?

19. Clinically hypoxia detection? Anaemic patient – never develop cyanosis until extremely cyanotic Polycythemia – appear cyanotic but well oxygenated How long human brain can survive without oxygen ? The brain can survive 5-10mts without oxygen only Upto 6 mts after heart stops without CPR After 6minutes without CPR – brain dies

20. CIRCULATION Peripheries – colour & temperature Pulse - Peripheral & central (both sides - radial/dorsalis or Posterior tibial ) Heart rate - high /low ; regular/irregular; ectopics (on monitor ) BP in both arms (low Diast . BP – arterial vasodilation; narrow pulse pressure – arterial vasoconstriction ) Other signs of ↓ circulation - ↓ Mental status, skin turgor, urinary output

21. BP measurement – difficult scenario? ( Irritable patient/ Both UL limb ≠ / Absent BP measuring device ) How to measure BP by pulse ? CAROTID - 60 mmhg RADIAL - 70 mmhg FEMORAL - 80 mmhg DORSALIS PEDIS - 90 mmhg Always have your hand on pulse – simple, time consuming but very much usefull parameter. ( tachy / bradycardia /ectopic /missed beat/ low/high volume )

22. Importance of MAP MAP (Mean arterial pressure) MAP = CARDIAC OUTPUT (CO) × SYSTEMIC VASCULAR RESISTANCE (SVR) NORMAL LEVEL = 70- 100 MMHG ( TARGET LEVEL > 65MMHG) DENOTES THE PERFUSION TO ORGAN & MINIMUM THRESHOLD BELOW OXYGEN DELIVERY IS DECREASED SHOCK INDEX Shock index = HEART RATE / SYSTOLIC BP Normal value = 0.5 - 0.7 Persistent elevation > 1 : Impaired LV function ( result of blood loss or cardiac depression ) - Implies high mortality rate

23. Circulation - Management Cardiac or noncardiac reason ? Fluid replacement, hemorrhage control, restoration of tissue perfusion Two large bore cannula , lab workup, crossmatching if bleeding suspected – Massive hemorrhage protocol (MHP) Fluid bolus over 15mts(250-500ml) – decide responder status If non fluid responder & worsening - Inotropes or vasopressors MONA therapy if ACS suspected ( morphine,oxygen,nitrate,aspirin )

24. P ersistent shock or hypotension? Does mentation & clinical appearance match degree of hypotension? Obstructive causes Cardiac tamponade, Pulmonary embolism, Tension Pneumothorax Drug/Toxin induced Adrenal insufficiency Retroperitoneal bleed

25. ULTRASOUND

26. V

27. DISABILITY Pupil size & reaction ? Level of consciousness – AVPU scale & GCS ? Lateralising signs ? Always consider BM in all patients with altered mental status. Anisocoria <30% its normal; but does not exceed >1mm difference Disabled & dementia patients – collateral history New onset or old; best motor response

28. GLASGOW COMA SCALE

29. Now, tell me the GCS ?

30. Altered mental status – AEIOUTIPS

31. EXPOSURE Signs of trauma – profuse bleeding ? Skin reactions/rashes ? Bite marks & Bruises ? Bleeding disorders ? Body temperature ?

32. Adjuncts to primary survey ECG ABG / Cap. blood gas Capnography Xrays E-FAST scans/AAA scan CONSIDER NEED FOR PATIENT TRANSFER Always important not to delay transfer to perform an in-depth diagnostic evaluation Only undertake testing that enhances the ability to resuscitate and ensure safe transfer

33. Secondary survey Focussed history & physical examination SAMPLE assessment S ymptoms or chief complaint A llergies M edications P ast Medical History  L ast Meal E vents leading up to the presentation

34. Top 10 reasons for an ED visit Abdominal pain Chest pain Fever Headache Back pain Shortness of breath Cough Vomiting Pain - various sites Throat symptoms

35. Cardinal rule in ER In a busy ER ,Pick up the sick patient Stabilise them and before seeing next patient Always assume the patient Every other patient is going to die or lose a limb On resuming to next patient Think of diagnosis that can kill in minutes/hours/days

36. Ten warning signs in history Sudden onset of symptoms Significant worsening of symptoms that was stable earlier True loss or altered conscious level Cardiopulmonary symptoms( dyspnoea,chest pain ) Extremes of age (newborn/elderly) Immune compromise ( HIV,AIDS,cancer,diabetes,immunosuppressant therapy – steroids or chemotherapy) Poor history due to various reasons Repeated visit to clinic or ED,ESPECIALLY recent Incomplete immunization Patient signed over at the end of shift

37. DD & your approach should be….. Likely diagnosis Deadly diagnosis Testing Treatment for deadly diagnosis (OUR MISSION)

38. EXAMPLE : 24 F Presented to ER with shortness of breath Give the deadly diagnosis which can kill her in next few minutes/hours/days

39. So the deadly DD’s are ? PE Pneumothorax MI Anaphylaxis Pericardial effusion Asthma Pneumonia CHF

40. RED FLAGS FOR HEADACHE

41. RED FLAGS FOR CHEST PAIN

42. RED FLAG FOR BACKPAIN

43. Telltale signs & symptoms in abdominal pain

44. Telltale signs & symptoms in abdominal pain

45. Manchester Clinical Reasoning Tool

46. Common missed diagnosis in A&E Atypical presentation of ACS (serial ECGs improve sensitivity). Unstable pts with AF with due to non-cardiac causes. ( sepsis,hypovolemia,PE,alcohol withdrawal) Non ACS causes of chest pain (AD, PE, Tension pneumothorax, cardiac tamponade, esophageal rupture) Syncope ECG interpretation Consider deadly causes of syncope –SAH, ruptured AAA/ectopic preg ., AD,PE,ACS Always consider the most serious possible cause of patients presenting signs and symptoms

47. Atypical presentation of appendicitis – children <5yrs, elderly, pregnant women Never delay pain medications for abdominal pain patients Acute mesenteric ischemia in abdominal pain pts with AF or younger pts with DVT . All patients with cirrhosis + UGI bleed are presumed to have variceal hemorrhage . Pancreatitis patients with normal amylase/lipase levels Common missed diagnosis in A&E Atypical presentations of serious disease are more common in elderly patients

48. CLINICAL DECISION MAKING Decision making can be: Analytical / conscious Pattern Recognition / unconscious – most commonly used, (~80%) Rule based Beware: High risk situations High risk clinical scenarios Pattern recognition Do: Critique your own reasoning Think beyond favoured diagnosis Reassess when new information arrives

49. Warning: Don’t fall into these traps

50. TAKE HOME MESSAGE Triaging & NEWS score for your patient Systematic ABCDE Approach & management Secondary survey Always remember the redflag’s or deadly DD’s Feedback your work to improve yourself. My rule for A&E – 5 seconds rule

51. Thank you ………