How to manage Emergency Patient ? easy learning

In most of the emergency condition, at first we should try to save the life of patient. The Basic and most important factors to investigate immediately are : Airway, Breathing and Circulation. After maintaining these three vitals further medical procedure are operated in the patient.  Everybody including health professionals should keep the idea of proper management of emergency conditions.

1. Rapid Initial Survey (RIS)

a. Airway maintenance by Cervicalspine control.

b. Breathing and ventilation

c. Circulation (pulses and hemorrhage control)

d. Disability (neurological status)

e. Exposure (complete) and environment (temperature control)

f. restart sequence from beginning if patient deteriorates.

Note : We should always care for signs of shock.

A. AIRWAY  : first priority is to secure airway

• Chance of cervical spine injury in every trauma patient. immobilize with collar.

• Ability to breathe and speak should be assessed.

• ask patient a question; appropriate response indicates patient airway & ability to breathe.

• signs of obstruction are as following :

– agitation, confusion, “universal choking sign”, – respiratory distress, – unable to speak i.e. dysphonia, – adventitious sounds, – cyanosis.

• REASSESS FREQUENTLY (especially if patient status changes).

Airway Management : goals

– permit adequate oxygenation and ventilation

– facilitate ongoing patient management

– give drugs via endotracheal tube (ETT) if IV not available

• Note : start with basic management techniques before progressing to advanced

1. Basic Airway Management

• protect the C-spine

• head-tilt chin lift or jaw thrust (if C-spine injury suspected) to open the airway

• sweep and suction to clear mouth of foreign material

• nasopharyngeal airway

• oropharyngeal airway (not if gag present)

• transtracheal jet ventilation (through cricothyroid membrane) used as last resort, if unable to ventilate after using above techniques

2. Definitive Airway Management

• endotracheal intubation (ETI) with inline stabilization of spine.

– orotracheal ± Rapid Sequence Intubation (RSI).

– nasotracheal - may be better tolerated in conscious patient.

– does not provide 100% protection against aspiration.

– contraindicated with basal skull fracture.

• indications for intubation : – unable to protect airway and inadequate oxygenation via spontaneous ventilation (O₂ saturation < 90% with 100% O₂ or rising pCO₂)

– profound shock.

– anticipate in trauma, overdose, congestive heart failure (CHF), asthma, and

chronic obstructive pulmonary disease (COPD)

– anticipated transfer of critically ill patients surgical airway (if unable to intubate using oral/nasal route)

– needed for chemical paralysis of agitated patients for investigations

– cricothyroidotomy

B. BREATHING :

• LOOK mental status like : anxiety, agitation, colour, chest movement (bilateral or

asymmetrical), respiratory rate/effort, nasal flaring and Loss of consciousness.

• LISTEN sounds of obstruction like: stridor, breath sounds, symmetry of air entry, air escaping

• FEEL flow of air, tracheal shift, chest wall for crepitus, flail segments, sucking chest wounds, subcutaneous emphysema.

Breathing Assessment

• measurement of respiratory function: rate, pulse oximetry, ABG, A-a gradient, peak flow rate.

Management of Breathing

• treatment modalities:

–        nasal prongs,  simple face mask with oxygen reservoir,  CPAP/BiPAP

–        Venturi mask: used to precisely control O₂ delivery.

– Bag-Valve mask and CPAP: to supplement ventilation

C. CIRCULATION

Definition of Shock : inadequate oxygen perfusion to organ and tissues like: brain, kidney & extremities.

Clinical Evaluation :

• rapidly assess for cause of shock and clinical features of hemorrhage.

– early: tachypnea, tachycardia, narrow pulse pressure, reduced urine output, reduced capillary refill, cool extremities and reduced central venous pressure (CVP).

– late: hypotension and altered mental status.

Management of Hemorrhagic Shock

• secure airway and supply O₂

TREAT THE CAUSE OF THE SHOCK!

1. Control external bleeding.
2. Apply direct pressure.
3. Elevate profusely bleeding extremities if no obvious unstable fracture.
4. Consider vascular pressure points (brachial, axillary, femoral).
5. Do not remove impaled objects as they tamponade bleeding.
6. Tourniquet only as last resort.
7. Prompt surgical consultation for active internal bleeding.
8. Infusion of 1-2 L of NS or RL as rapidly as possible.
9. Replace lost blood volume at ratio of 3:1 (maintain intravascular volume)
10. If inadequate response, consider ongoing blood loss e.g. chest, abdomen, pelvis, extremities then operative intervention is required.

 Indications for blood transfusion :

–  Severe hypotension on arrival.

–  Shock persists following crystalloid infusion.

– Rapid bleeding.

–  Transfusion options with packed red blood cells (PRBCs).

– Cross-matched (ideal but takes time).

– Type-specific (provided by most blood banks within 10 min.).

–  Preferred to O-negative uncross-matched blood if both available.

–  O-negative (children and women of child-bearing age).

–  O-positive (everyone else) if no time for cross and match.

–  anticipate complications with massive transfusions.

# Transfusion options with fresh frozen plasma (FFP).

–        Used for clinical evidence of impaired hemostasis.

–        Ongoing hemorrhage and platelet count < 50,000, PT > 1.5 x normal range.

# vasopressors

–        Used if hypotension persists despite appropriate volume resuscitation

–        Dobutamine 2.0-20.0 mcg/kg/min for systolic BP over 100 mmHg

–        Dopamine 2.5-20.0 mcg/kg/min for systolic BP 70 to 100 mmHg

–        Norepinephrine 0.5-30.0 mcg/kg/min for systolic BP < 70 mmHg

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