Approaching an acutely ill

Ihab B Abdalrahman, MBBS, MD, ABIM, SSBB
Assistant Professor of Medicine
Consultant of acute Care Medicine
Introduction to
Emergency Medicine
Ihab Tarawa 11/29/2012 1

Emergency

 An emergency is a situation that poses
an immediate risk to:
 health,
 life,
 property,
 environment.


Most emergencies require urgent intervention
to prevent worsening of the situation.
.


Key emergency principle

 The key principles are:
 assess the situation for danger.
 observation of the surroundings, starting with the
cause of the event.


Who should Help


Structured thought process


From what is inside,

To the bedside

 Applying “book learning” to a specific clinical
situation is one of the most challenging
tasks in medicine.


• Retain information

• organize the facts

• recall large amounts of data


 It is challenging to apply these information in
right context

Critical decisions Low resources Reassure


Backward Vs forward

Traditional
medicine
Emergency Medicine
 We learn in one direction

Anatomy Pathology Treatment
Clinical Investigations
applied
Physiology Microbiology presentation lab & radiology
pharmacology

We receive patient in other direction


The presentation is not
specific

Chest pain
Cardiac Pulmonary
Esophageal
MI Embolism
GERD
USA Pneumothorax
Spasm
Pericarditis Pneumonia


The same disease my have
different presentation

CP

Weakness SOB

MI
Arrest Syncope

Palpitation


Traditional medicine

Chief complaint

HPI

System review

PMH

FH

SH

DH


Examination

 Vital
 General
 Systems
 CVS
 Chest
 Abdomen
 Genital
 Legs
 CNS

lab & radiology

 CBC
 RFT
 LFT
 CXR
 US
 CT
 ECG
 MRI

 What about emergency medicine


APPROACH TO CLINICAL PROBLEM-
SOLVING
 There are typically five steps that an ED
clinician undertakes to systematically solve
most clinical problems:


Following the patient’s response
to the treatment

Treating based on the stage of the
disease

Assessing the severity of the disease

Making the diagnosis

Addressing the ABCs and other life-
threatening conditions

Emergency Assessment and
Management
 Patients often present to the ED with life-
threatening conditions that necessitate
simultaneous evaluation and treatment.


Pneumothrax CHF PE

O2

C
lab
SOB X
R

Asthma Vent Pneumonia


 a comatose multi-trauma patient first
requires intubation to protect the airway.


 A tension
pneumothorax
needs an
immediate
needle
thoracostomy.


Take home CLINICAL PEARL

 Because emergency physicians are faced with
unexpected illness and injury, they must
often perform
 diagnostic and simultaneously.
 therapeutic steps


Take home Step # 1 ABC

 In patients with an acute life-threatening
condition, the first and foremost priority is
stabilization— the ABCs.


 A airway is open
 Breathing
 Circulation


 Determination of
breathlessness.
 The rescuer
“looks,
listens, and
feels” for breath.


 Head tilt
Chin lift


Jaw-thrust
maneuver
lift the
mandible
upward
while
keeping the
cervical
spine in
Neutral
position

Chest compressions

Rescuer applying
chest compressions
to an adult victim


Step 2
making a diagnosis
 Once the ABCs and other life-threatening
conditions are stabilized, a
more complete history and head-to-toe
physical exam should follow


Step 2
making a diagnosis
 This is achieved by:
 carefully evaluating the patient,
 analyzing the information,
 assessing risk factors,
 and developing a list of possible diagnoses (the
differen-tial).


Step 2
making a diagnosis


 Usually a long list of possible diagnoses can
be pared down to a few of the most likely or
most serious ones, based on the clinician’s
knowledge, experience, and selective testing.


Step 3
Assessing the Severity of the
Disease
 After establishing the diagnosis, the next step
is to characterize the severity of the disease
process.


Assessing the Severity of the
Disease
 Formal staging may be used
 For example, the Glasgow coma scale is used in
patients with head trauma.


 43 year
 Female
 Supra pubic pain for 2 days
 Dysuria and fever,
 Loin pain
 HR 80, BP 116/70, RR 18, Sat 98%


 70 year
 Female
 Loin pain
 Diabetic
 HR 110, BP 100/50, RR 28, Sat 98%


 70 year
 Female
 Loin pain
 Diabetic
 HR 156, BP 70/50, RR 44, Sat NA%


Take home

 The third step is to establish the severity or
stage of disease.
 This usually impacts the treatment and/or
prognosis.


Scenario Ca, healthy

 56 Y male with HTN, DM smoker. Presented
with CP. ECG STEMI

 78 male with stage 4 Ca lung on NGT feeding,
developed SOB. ECG STEMI


Step 4
Treating Based on Stage
Many illnesses are characterized by stage or
severity because this will affects prognosis
and treatment.


Step 5
Following the Response to Treatment
 The final step in the approach to disease is to
follow the patient’s response to the therapy.
 Some responses are clinical such as
improvement (or lack of improvement) in a
patient’s pain.



 Other responses may be followed by testing
(e.g., monitoring the anion gap in a patient
with diabetic ketoacidosis).



 The clinician must be prepared to know what
to do if the patient does not respond as
expected.
Treat again

Reassess
Not
responding Different
test

Consult


CLINICAL PEARL

 The fifth step is to monitor treatment
response or efficacy.
 This may be measured in different ways:
 Symptomatically
 based on physical examination
 other testing.


Key parameter in ER

 For the emergency physician,
 the vital signs,
 oxygenation,
 urine output,
 and mental status .


SUMMARY

 There are five steps in the clinical approach to
the emergency patient:
 addressing life-threatening conditions,
 making the diagnosis,
 assessing severity,
 treating based on severity,
 and following response.


 Thanks


ABCDE APPROACH

Ihab Tarawa 11/29/2012

How to recognize critically ill
patients


Learning Objectives

-How to recognize a critically ill patient
early.
-How to identify and treat patients at risk of
cardio respiratory arrest using ABCDE
approach.


Medical emergency team calling criteria:

Acute Change in: Physiology:

Airway: Threatened

Breathing: All respiratory arrest
RR < 5/min or > 36/ min

Circulation: All cardiac arrest
Pulse rate < 40/min or > 140/min
Systolic BP < 90 mmHg
Neurology: Sudden decrease in level of
consciousness
Decrease of GCS of > 2 points
Repeated or prolonged seizures
Others: Any concern doesn’t fit above criteria


Principles of management

Assess

Monitor Manage


Underlying principals:

2.Treat life threatening conditions before
moving to next step of assessment.
3.Call for help early.
4.Reassess regularly.
5.The aim is to keep patients alive and
achieve clinical improvement as an initial
step for full management.


Ensure personal
safety then check
response

If patient appear If appears
awake ask (how are unconscious , shake
you?) and obtain and shout (are you
brief Hx alright?)

- Patent airway
- Breathing
Normal response No response
- Maintained
cerebral circulation

Complete ABCDE Complete ABCDE
ALS Algorithm
approach approach


Airway:
- Signs of airway obstruction (partial-complete).
- Treat as (medical emergency)
* airway opening maneuvers
* Simple airway adjuncts.
* expert help for definitive airway
management (endotracheal intubation)
-Give O2 using a face mask ( initially 10 L/min)


Head Tilt & chin lift Jaw Thrust


Breathing:
Aim: Exclude and treat life threatening
conditions.
-pulmonary edema, acute severe asthma, tension
pneumothorax, massive hemothorax, PE.
-Assess: simple chest examination
( inspection, palpation, percussion, auscultation)
-Treat any problem encountered.
-Monitor: pulse oximeter (O2 saturation)
-Note : if O2 saturation < 94% --» increase
O2 flow to 15 L/min.

Circulation:

-Assess: *pulse (all characteristics) *BP
If compromised: Hypovolemic shock until proved
otherwise.
-Manage: 2 wide bore canulae, draw blood for
routine ( CBC, RFT, LFT, RBG, Blood grouping and cross matching)
special (e.g. Cadiac enzymes)
Take arterial sample for ABG

*infuse IV 1 L crystalloid if hypotensive
500 ml crystalloid in normotensive
250ml crystalloid in cardiac patients.


Monitor: by attaching the monitor
(assess & treat tachycardias and
bradycardias)
-ask for 12 lead ECG if needed and
consider early consultation.


Disability:
Common causes of unconsciousness:
-Profound hypoxia, hypercapnia, cerbral hypoperfusion,
sedatives
Assess:
- AVPU scale for consciousness level
- examine pupils (size, equality, reactivity to light)
- use glucometer for bed-side blood glucose level →to
exclude hypoglyceamia.
-if below 3 mmol/ L → 50 ml of 10% Dextrose
Notes:
*review patient drug chart
*nurse unconscious patient in lateral position if airway
is not secured.


Exposure:
With respect to patient dignity and
minimizing heat loss, expose the patient’s
body fully for assessment (rash, hemorhage,
DVT,….etc.)


REASSES AGAIN


The ABCDE approach
Airway Circulation
Assess patency, PR, BP, Capillary refill time.
Open airway Manage accordingly
Maintain patency, Attach to rhythm Monitor
Consider definitive airway Disability
Breathing Pupils
Assess breathing Glucose check
Manage and give O2 AVPU scale
Monitor by pulse oximeter & Exposure
ABGs
Fully exposure & examination


QUESTIONS


 Thank you


Approaching an acutely ill

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