Heike Geduld, Division of Emergency Medicine, UCT/SUN HELP: The management of common emergencies

Objectives Goals for managing the emergency patient Preparing for an emergency Recognition of the unstable patient A system for managing the emergency patient Cases: common and important conditions Major incidents

Goals Keep the patient alive Fix the things you can fix Provide quality care Get them to definitive care rapidly DIAGNOSIS IS NOT THE GOAL, STABILISATION IS

Questions to ask yourself with every patient Is this patient sick or not sick? Is this patient stable or unstable? If unstable, why? What should you do immediately? What will happen if you don’t treat him properly? What do you anticipate this patient will need next?

Presentations and syndromes, not diagnosis Sharks and Lions and Hippos! exclude life threatening conditions first If you hear hoofbeats think horses not zebras! the most common diagnosis is the most likely

“You cannot make a diagnosis that you do not think of!” - Dr. Phil Rice not think of!” - Dr. Phil Rice You should always have a mental list of possibilities you are considering The “differential diagnosis” must include AT LEAST three items: MOST COMMON THING MOST LIKELY THING MOST DEADLY THING Narrow down the possibilities as you ask questions and do exam

Why a different approach? Critically ill and injured patients require different approach History often difficult to obtain Management cannot be delayed until diagnosis made Treatment instituted whilst assessment is ongoing

Algorithms Use a structured approach Starts with most life threatening and then moves to next Each component is assessed If there is a problem, it is corrected Only then moved to next component

Warning signs Increased respiratory rate Tachycardia Cold extremities Anxious or mildly confused patient Increased gap between systolic and diastolic BP (pulse pressure) Pain

Algorithm 3 H’s Hazards Hello Help PRIMARY ASSESSMENT Primary ABCs Circulation Airway Breathing Defibrillation Secondary ABCs Circulation Airway Breathing Disability Exposure AMPLE History Radiology, Other Investigations SECONDARY ASSESSMENT Head to Toe Survey

Circulation is the new A CAB rather than ABC Rapid initiation of chest compressions Where there is more than 1 provider, circulation and airway happen in tandem

Primary Assessment – 1  ABCs CirculationAssessment Feel for a pulse (<10s) Carotid or femoral; Brachial in infant Assess perfusion Capillary Refill Time; Radial pulse present Basic Circulation intervention Chest Compressions If no pulse or child <60 with poor perfusion

Primary Assessment – 1  ABCs Attach the monitor If needed then Defibrillation occurs now: Cardiac Arrest in Ventricular Fibrillation or pulseless Ventricular Tachycardia

Primary Assessment – 1  ABCs Airway (C-Spine control) Airway (C-Spine control) – Assess if patent No gurgling No gurgling No stridor No stridor – Basic Airway corrections Suctioning Suctioning Head tilt chin lift or jaw thrust (if trauma) Head tilt chin lift or jaw thrust (if trauma) OPA OPA – Remember to protect the C-Spine if injury suspected

Primary Assessment – 1  ABCs Breathing (and Oxygenation) Assess presence of breathing Look, listen, feel Basic Breathing intervention Bag-Valve-Mask Ventilation 2 breaths if not breathing and continue compressions Assist Breathing if inadequate ventilation Give Oxygen

Primary Assessment – 2  ABCs AirwayAssessStridorGurgling Intubate if needed If doing CPR then IV access and drugs more important than intubation

Primary Assessment – 2  ABCs Breathing Breathing – Assess Respiratory rate Respiratory rate Effort of breathing Effort of breathing IPAP (Inspection, palpation, auscultation, percussion) IPAP (Inspection, palpation, auscultation, percussion) Efficacy of breathing Efficacy of breathing – Manage Oxygen Oxygen Nebulisation Nebulisation Ventilation Ventilation – Attach monitors related to B (Pulse Sats; ETCO2) (Pulse Sats; ETCO2)

Primary Assessment – 2  ABCs CirculationAssess Heart rate Blood Pressure Organ Perfusion Skin – CRT Brain – LOC Kidneys – Urine Output

Primary Assessment – 2  ABCs CirculationManage IV lines Fluid Manage Arrhythmias Catheter and NGT Inotropes if needed Take bloods whilst putting up lines Gluc, Hb, FBC, CEU, G&S, Pregnancy

Primary Assessment – 2  ABCs DisabilityGCS Pupil response Gross neurological state

Primary Assessment – 2  ABCs Exposure Look for extremity trauma Prevent Hypothermia

SAMPLE S = Signs and symptoms A = Allergy M = Medication taking P = Past history (medical/surgical) L = Last meal E = Events leading up

Investigations RadiologyCXRC-spinePelvis Other Investigations

Secondary Assessment Head to toe survey Back and front of patient Make sure that everything that should bend does and everything that shouldn’t bend doesn’t!

Prepare for transport Prepare the Patient Prepare the Receiving facility Prepare the Documentation Prepare the Transportation System

Practical Cases Your worst experiences…

Choking Neonatal resus Collapse Shortness of breath Seizures Cardiac arrest

Major Incident Medical Management

Command and control Safety Communication Assessment Triage Treatment Transport

Communication Who to call Emergency Services 107 from landline, or 112 from mobile Police EMS Fire

Critical Message Structure MMy name and contact number EExact location (GPS) TType of incident HHazards, present and potential AAccess, and egress NNumber and severity of casualties EEmergency services, present & required

BRONZE SILVER 1 23 SC ICP IN OUT

Triage “Do the most for the most” Triage Sieve 3 categories: Green (walking wounded); Yellow and Red

Resources Youtube: EM Cape Town channel Apps: Simmon Iresus Webicina

So to conclude Be prepared Don’t Panic Trust your clinical judgement Stick to a system Sometimes people die

We can work it out Heike Geduld gov.za