1/31/2011 OBJECTIVES

OBJECTIVES
IMMEDIATE RESPONSE:
• Emergencies: Patient Approach
1/31/2011
Medley O’Keefe Gatewood, MD
Assistant Professor
Division of Emergency Medicine
University of Washington Medical Center
Harborview Medical Center
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Airway Issues
Oxygen Supplementation
Shock Care
Acute Coronary Syndromes
Cardiac Arrest
The Seizing Patient
Questions & Answers
“Traditional” Medical Approach
• History (Medical Record)
• Physical Exam
• “Diagnostic”
“Di
ti ” St
Studies
di
• Synthesis of the above
• Differential Diagnosis
• Working Diagnosis
• Further Diagnostic & Treatment Plans
EMERGENCY / CRITICAL CARE
• Primary Survey & Resuscitation
• C-Spine ?  A-B-C-D-E…
– C-A-B-D-E… pulse check
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Airway & Spinal Stabilization
Breathing & Ventilation
Circulation & Hemorrhage Control
Disability & DON’T Regimen
Exposure & Environmental Control
• Secondary Survey
• Definitive Care
Three PILLARS for Patients in
TROUBLE
“Safety N et”
Vital Signs
O xygen
IV A ccess
M onitors
P
BP
RR
T
O 2 sat
O thers
Prim ary
Survey
A + Spine
p
B +V
C + Hem cntrl
D + “DO N ’T”
E + Env
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OBJECTIVES
• Emergencies: Patient Approach
• Airway Issues
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Oxygen Supplementation
Shock Care
Acute Coronary Syndromes
Cardiac Arrest
The Seizing Patient
Questions & Answers
Positioning
THE HUMAN AIRWAY:
AIRWAY: A CONTINUUM…
• Awake & Alert: No Intervention
• Inadequate?
– Positioning
– Head Tilt / Jaw Thrust
– Nasopharyngeal Airway
– Oropharyngeal Airway
– Bag Valve Mask Ventilation
– Supraglottic Airway (LMA, etc)
– Endotracheal Intubation
• “Impossible?”  then one of the following…
– Jet Insufflation
– Surgical Airway: Cricothyroidotomy > 8-12 yo
Bagging a Patient:
Head--Tilt Chin Lift
Head
• Extend the patient’s head slightly (‘sniffing position’)
• Do NOT do this with C-Spine precautions
• Jaw Thrust
• OK to do this with C-Spine precautions
 ‘Head-Tilt Jaw-Thrust’
Bagging a Patient: Jaw Thrust
Sizing & Placing an Oral Airway:
Angle of the
mandible to
corner of the lips
Start upside down
and rotate 180°
180°
mid--insertion
mid
2
Sizing & Placing an Oral Airway:
Sizing Nasal Trumpet(s):
Measure from
nare to earlobe
Start upside down
and rotate 180°
180°
mid--insertion
mid
Bagging a Patient: 1 or 2 hands
Bagging a Patient: 1 hand
Bagging a Patient: 1 hand
Bagging a Patient: 2 hands
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Bagging a Patient: 2 hands
The Bag Valve Mask
Bagging a Patient: Equipment
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BVM with reservoir
Oxygen connector tubing
Oxygen source (turn it all the way up)
Suction (check it!)
Nasal pharyngeal airway (NPA = ‘trumpet’)
Oral pharyngeal airway (OPA)
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King Systems Supraglottic Airway
REVIEW Questions
OBJECTIVES
• A patient is seizing in the room, breathing is
stertorous.
– Size and place the correct airway (s).
• Emergencies: Patient Approach
• Airway Issues
• Oxygen Supplementation
• A patient presents with altered mentation. A,
B, and C are fine. What do you do at the “D
part” of the 1° survey?
BASIC OXYGEN THERAPY
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Nasal cannula
Simple face masks
Venturi masks
Non-rebreather masks
Bag-valve-mask apparatus
NIPPV
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Shock Care
Acute Coronary Syndromes
Cardiac Arrest
The Seizing Patient
Questions & Answers
OXYGEN SATURATION
GOALS
• Most patients ?
• Pregnant (3rd trimester) ?
• COPD patients & CO2 retention ?
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The DON’T Regimen in
ALTERED MENTATION
• D = Dextrose
• O = Oxygen
• N = Naloxone
• T = Thiamine
CLINICAL CASE
You are working in the ED.
A car drives up, unloads a woman onto
the ambulance bay,
y and then drives off
You and your staff run out to find a
woman in her early 30’s, comatose, with
facial abrasions, breathing poorly, slightly
cyanotic, and with a weak femoral pulse.
CARE for HER Now!
CLINICAL CASE: Emergency Care
(continued)
• IV, Labs, normal saline wide open
• D = disability (comatose, pupils,
symmetry) & DON’T regimen
• E = expose, Temperature check,
rewarm, safety
• “AMPLE” History
• Secondary Survey: OG Tube, Foley
catheter, Head CT, ADMIT ICU
CLINICAL CASE: Emergency Care
• HELP!
• Jaw Thrust -- Logroll--Backboard—
Inside ED
• “Safety
“S f t Net,”
N t ” Vital
Vit l Si
Signs
• Hard collar, strapped to board, cut
clothes off, warm blanket
• OP Airway, Bag-Valve-Mask, ET tube,
Confirm Tube, Ventilator
Differential Diagnosis of
ALTERED MENTAL STATUS
• T = trauma, temp.
• I = infection
• P = psychiatric
• A = alcohol,
ammonia (liver failure)
• E = electrolytes,
y ,
endocrine
causes
• S = space
occupying lesions,
stroke, seizure,
SAH, subdural
hematoma
• I = insulin
• O = opioids, oxygen
•
(lack of)
U = uremia
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SHOCK Worksheet
OBJECTIVES
• Emergencies: Patient Approach
• Define Shock
• Airway Issues
• Identify at the Bedside
– CC/Hx
– Vital Signs
– Skin
– Capillary refill
– Neck veins
– Urine Output
– Mental Status
• Oxygen Supplementation
• Shock Care
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Acute Coronary Syndromes
Cardiac Arrest
The Seizing Patient
Questions & Answers
SHOCK Worksheet
• Other Adjuncts…
• EKG
• pCXR
• Bedside
B d id ultrasound
lt
d
– Cardiac
– Pneumothorax
– IVC
– Free blood (in abdomen)
Clinical Case: HEMORRHAGE
Mr. AJ, 59-year-old.
History alcohol & cigarette use.
Vomiting blood, melena, postural
symptoms.
t
Looks ill.
VITAL SIGNS: P 125 bpm, BP 88/55, RR 26, T 36.0 C
CARE FOR THIS MAN NOW!
THE CARDIOVASCULAR TRIAD
• Rate / Rhythm Problem (e.g., Afib with
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rapid ventricular response, VTACH)
Pump Problem
– Primary Pump Problem (e
(e.g.,
g MI
MI, CHF)
– Secondary Pump Problem (e.g., tension
pneumothorax, tamponade, PE)
• TANK PROBLEM
– Pure Volume Problem (e.g., GI bleed,
abdominal trauma, gastroenteritis)
– Volume/Resistance problem
Teaching Questions SHOCK
1. Normal saline or lactated
2.
3.
4.
5.
6.
Ringer’s?
When to avoid lactated
Ringer s?
Ringer’s?
Hematocrit drop by dilution?
Universal donor?
Platelet counts?
Coagulopathy?
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VOLUME Resuscitation
• Normal Saline
• Lactated Ringer’s
– Na 154 mEq/L
– Cl 154 mEq/L
q
– Na 130 mEq/L
– Cl 109 mEq/L
q
–K
4 mEq/L
– Ca
2.7 mEq/L
– Lactate 28 mEq/L
3:1 crystalloid to blood…
Common PRESSORS
• DOPAMINE
– dopamine-receptors, beta-, alpha– Dose: 2-5 ug/kg/min, 5-10 ug/kg/min, >
10 ug/kg/min
/k / i IV
• NOREPINEPHRINE
– alpha-, beta– Dose: 2-20 ug/min IV
• Epi, Dobutamine, Neosynephrine…
OBJECTIVES
• Emergencies: Patient Approach
Clinical Question
• Airway Issues
What are the
RISK FACTORS for
Coronary Artery
Disease?
• Oxygen Supplementation
• Shock Care
• Acute Coronary Syndromes
• Cardiac Arrest
• The Seizing Patient
• Questions & Answers
The Symptoms of Acute
Myocardial Ischemia
• Chest Pain / Pressure / Heaviness
• Associated Symptoms
• Dyspnea
• Atypical Symptoms
(or, how will you be “fooled?”)
Question
List as many LifeThreatening causes
of Chest Pain as you
can.
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Life-Threatening Chest Pain
• Acute coronary
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syndromes
Aortic dissection
Aortic stenosis
(critical)
Cancer
Empyema
Esophageal injury
Tamponade
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Mediastinitis
Myocarditis
Pancreatitis
Pneumonia
Pneumothorax
Pulmonary
Embolism
Pulmonary
hypertension
The SPECTRUM of
Coronary Artery Disease
• Asymptomatic Atherosclerosis
g
• Stable Angina
• Unstable Angina
• Non-ST-Elevation MI
• ST-Elevation MI or
New LBBB MI
Clinical Case
Ms. HD: 60-year-old female with 3-hr of 6/10 chest
pain + jaw pain + diaphoresis.
Risks: age, Fam Hx, HTN.
MEDS: HCTZ; ALL: NKDA
EXAM: uncomfortable older woman
VS: P 90, BP 160/100, RR 20, T 37.2 C
Lungs: clear
Heart: regular, ? S4
CARE FOR HER NOW!
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Initial Acute
CORONARY SYNDROME CARE
• “Three Pillars”:
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– Safety Net – Vital Signs –(C) A B C Ds
ECG & Chest Radiograph (portable)
Vital Sign Support (? Fluids; ? Dopamine)
Differential & Working Diagnosis
M O N A (B) P + Heparin (or LMWH)
? ST-Elevation MI: then PTCA or
Thrombolysis
WARNING: Unstable Angina!
Initial Care: MEDS
• M = Morphine (2-4 mg IV; repeat prn)
• O = Oxygen (O2 sat > 95%)
• N = Nitroglycerin (0.4 mg SL)
• A = Aspirin (325 mg bite & swallow)
• B = Beta Blocker (metoprolol 5 mg X3)
• P = Plavix (600/300 mg po)
• H = Heparin
Objectives
• Emergencies: Patient Approach
• Airway Issues
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Definition ___________
Death: 5-10%
Non-Fatal MI: 10-20%
Most of the above within days to weeks
of symptom onset
• Curr Prblm Cardiol 1999;24:681-744.
• Oxygen Supplementation
• Shock Care
• Acute Coronary Syndromes
• Cardiac Arrest
• The Seizing Patient
• Questions & Answers
Clinical Case
Your 60-year-old female patient
previously presented now
suddenly
y “rolls up”
p her eyes
y and
loses consciousness. She is
completely unresponsive.
CARE FOR HER NOW!
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The ACLS “Surveys”
Primary
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A-B-C  C-A-B!!!
Call for help; get AED
If alone
alone, call 911
911, get AED  follow prompts
No AED  CPR x 30 compressions
Airway: assess & open (head-tilt, jaw thrust)
Breathing: provide x2
Repeat 30/2
Defibrillate: when AED or Life-Pak arrives
The ACLS “Surveys”
Other ACLS Changes…
• No cricoid pressure for lay or healthcare BLS
• No more ‘look-listen-feel’  ‘hands-only CPR’
• Even for healthcare providers, empahsis is on
early quality CPR
– Airway has been un-throwned!!!
– But not forgotten…
The ACLS “Surveys”
Secondary
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Airway: advanced intervention
Breathing: confirm & secure tube
Circulation: IV access & Meds
Differential Diagnosis
Review Question
In an adult patient, what are the
answers to the following as they relate
to CPR?
• Compression Rate
• Depth of Compressions
• Ventilation to Compression Ratio
• UN-Intubated
• Intubated
• Ribs Cracking?
Case (continued)
Your patient is unresponsive.
A “Code” is called & CPR is ongoing.
You attach your unresponsive patient to the
cardiac monitor and see the following:
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VFib or Pulseless VTach
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SHOCK (200 J vs. 360 J)
y resume CPR
Immediately
Perform 5 cycles of CPR
Then, ASSESS response
VFib or Pulseless VTach
• Shock
• Everybody
E
b d – Shock
Sh k
E = Epinephrine (1 mg IV q 3-5 min)
• Anybody – Shock
A = Amiodarone (300 mg IV)
Review: “C-A-C” and then . . .
Secondary
Primary
• C-A-B-C
• Pulse check: CPR
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(
(AED/Defib)
)
Airway: assess &
open
Breathing: provide
Circulation: CPR
Defibrillate:
• Airway: advanced
intervention
• Breathing:
g confirm &
secure tube
• Circulation: IV
access & Meds
• Differential
Diagnosis
OBJECTIVES
• Emergencies: Patient Approach
• Airway Issues
• Oxygen Supplementation
• Shock Care
• Acute Coronary Syndromes
• Cardiac Arrest
• The Seizing Patient
• Questions & Answers
Clinical Case
This 58-year-old male presents
for routine follow-up after recent
hospitalization for a left brain
stroke.
stroke
The patient lays down on the
examination table – and begins to
suffer a grand mal seizure.
CARE FOR HIM NOW!
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The SEIZING Patient
• Protect from HARM!
The SEIZING Patient (cont’d)
• Benzodiazepine: LORAZEPAM 2 mg IV
(may repeat every min up to 8 mg)
• Trendelenberg – suction – airway (NP)
• DILANTIN: 15-18 mg/kg IV load at 50
• Oxygen – IV access
• Fingerstick glucose – give DEXTROSE if low
mg per min
• Others: MAGNESIUM, more DILANTIN,
PHENOBARBITAL, PROPOFOL, etc.
OBJECTIVES
• Emergencies: Patient Approach
• Airway Issues
• Oxygen Supplementation
• Shock Care
• Acute Coronary Syndromes
• Cardiac Arrest
• The Seizing Patient
• Questions & Answers
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