Clinical Examination in Emergency Department

The objective 1. able to examine emergency cases systematically 2. able to determine priority of the emergency situation 3. able to treat emergency situation according to the priority 4. able to monitor continuously

The difference in managing an emergency patient Immediately do PRIMARY SURVEY first, anamnesis later and Treat the life-threatening condition first

Emergency department : Trauma patient Non trauma patient

Tri-modal Distribution of Death (Trankey) IMMEDIATE: CNS injury, or heart and great vessel injury 50 I/R injury Inflammation Tissue hypoxia 40 EARLY: major hemorrhage 30 LATE: infection and multi organ failure Percent of trauma deaths 20 10 1 2 3 4 hrs 1-2 5-6 weeks Time after injury

First 24 hours are the most crucial in trauma care delivery Primary goals : primary injury prevention enforcement of protective mechanisms, early identification of injuries, improvement in emergent care early treatment of potentially lethal injuries

Principles of emergency management : Organized team approach    Priorities in management and resuscitation    Assumption of the most serious injury    Treatment before diagnosis    Thorough examination    Frequent reassessment    Monitoring

Standard precautions Cap Gown Gloves Mask Shoe covers Goggles/face shields

Triage Sorting of patients according to: Multiple casualties ABCDE’s : red, yellow,green available resources Multiple casualties Mass casualties Adult/pediatric/pregnant women=priorities are the same

Physical examination in emergency patient Primary survey : A,B,C,D,E,F Secondary survey : Neurologic Cardiac Abdomen/pelvis Musculoskeletal Soft tissue

Primary Survey ruling out the presence of life-threatening or limb-threatening injury Life-threatening injuries take priority over limb threatening injuries initial assessment (the primary survey) and necessary initial resuscitation efforts must occur simultaneously Do NOT proceed to Secondary Survey until ABC's are stable

assessment and resuscitation should be addressed within the first 5 to 10 minutes of evaluation potentially serious or unstable injury requires continual reassessment Vital signs should be repeated every 5 minutes during the primary survey and every 15 minutes thereafter until the patient is considered stable.

Primary Survey A : airway and cervical spine stabilisation B : breathing and ventilation C : circulation and hemorrhage control D : disability assessment (thorough neurologic examination) E : exposure and thorough examination F : family

Airway and cervical spine stabilisation Possible airway obstruction ? Noisy breathing is obstructed breathing But not all obstructed breathing is noisy breathing Blood, emesis, teeth Anticipate airway problems with : Decreased level of consciousness Head/ facial/neck /upper thorax trauma Severe burns to any of these area

Stabilizing the neck + jaw thrust maneuver Clear the oropharynx of debris Consider cervical cord injuries in all seriously traumatized patients OPEN, CLEAR, MAINTAIN

Jaw thrust

Breathing and ventilation Assessment : determining the adequacy of the ventilatory effort the presence of chest injuries that may compromise oxygenation Observe : rate and quality of respirations labored or accelerated respirations penetrating wounds flail segments distended neck veins tracheal deviation.

Oxygenate immediately if : Decreased level of consciousness Shock Severe hemorrhage Chest pain Chest trauma Dyspnea Respiratory distress Multi- system trauma

Consider assisted ventilation if : Respiration rate < 12 Respiration rate > 24 Tidal volume decreased Respiratory effort increased If ventilations are compromised in trauma patients  expose, palpate, auscultate the chest

Respiratory failure  ventilation assisted Initially : bag valve mask Excessive volume or rate  gastric distension  impair ventilation further Cricoid pressure may be usefull

Breathing and ventilation Indication endotracheal intubation: any inability to ventilate by bag/valve/mask methods or the need for prolonged control of the airway Glasgow Coma Scale (GCS) score < 9 to secure the airway and provide controlled hyperventilation as indicated respiratory failure from hypoxemia (e.g., flail chest, pulmonary contusions) or hypoventilation (injury to airway structures) the presence of decompensated shock resistant to initial fluid administration

Airway management : Orotracheal intubation Nasotracheal intubation Surgery : crycothyrotomy , etc Fiberoptic intubation

Intubation

Ventilatory problems related to a pneumothorax or hemopneumothorax may require a thoracostomy tube. A chest radiograph may be obtained before tube placement if the patient's condition permits. Signs of cardiopulmonary compromise or a tension pneumothorax tracheal deviation distended neck veins Hypotension deteriorating oxygenation require immediate treatment before a chest radiograph is obtained.

Tension Pneumothorax

Circulation and hemorrhage control Is the heart beating ? Is there serious external bleeding ? Is the patient perfusing ?

Circulation : Does patient have radial pulse ? Absent radial : systolic BP < 80 Does patient have carotid pulse ? No carotid pulse ? CPR !!!!

All bleeding stops eventually External bleeding : Direct pressure : hand, bandage All bleeding stops eventually

Is the patient perfusing ?? Cool, pale, moist skin Capillary refill > 2 sec Restlessness, anxiety, combativeness Internal hemorrhage ?? Expose, palpate abdomen, pelvis, thighs

Shock : prompt diagnostic and therapeutic intervention Treatment : Improving perfusion by volume resuscitation and inotropic Control of any ongoing hemorrhage

Choice of resuscitation fluid : IV LINE : Peripheral vein large bore catheter Venous cutdown Large bore central line placement Intraosseus line Choice of resuscitation fluid : Crystalloid Coloid Blood

Disability assessment (thorough neurologic examination) AVPU GCS

Disability assessment (thorough neurologic examination) Conciousness Check pupils : The eyes are the windows of the CNS AVPU A : Alert V : Respond to verbal stimuli P : Respond to painful stimuli U : Unresponsive

Disability assessment (thorough neurologic examination) GCS Eye opening response : 4 : spontaneous 3 : to verbal command 2 : to pain 1 : none

GCS : Glasgow Coma Scale Motor response : 6 : obeys commands 5 : localizes pain 4 : withdraws to pain 3 : abnormal flexion to pain (decerebrate) 2 : abnormal extension to pain (decorticate) 1 : none

GCS : Glasgow Coma Scale Verbal response 5 : Oriented and converses 4 : Confused conversation 3 : Inappropriate words 2 : Incomprehensible sounds 1 : None

Total score key : Severe < 9 Moderate 10 – 13 Mild 14 – 15

Decreased of consciousness : Brain injury Hypoxia Hypoglycemia Shock NEVER think drugs, alcohol or personality first

Exposure and thorough examination Fully undressing the patient to assess for hidden injury Maintenance of normothermia, cover patients with blanket when finished You can’t treat what you don’t find

Family Rapidly informing the family of what has happened The evaluation that is proceeding helps lessen the stress of the caregivers Allowing family members to be present during resuscitations is acceptable If a caregiver is present, it is advisable to assign a staff member to be with him or her during the trauma resuscitation to explain the process.

Secondary survey Assesses the patient and treats additional injury not found on the primary survey Obtains a more complete and detailed history AMPLE A : Allergies M : Medications P : Past Medical History L : Last meal E : Environments and events

Secondary survey Tasks to be completed after secondary survey : Complete head-to-toe examination    Appropriate tetanus immunization  (trauma)  Antibiotics as indicated Continued monitoring of vital signs Ensure urine output of 1 mL/kg/hr

Secondary survey Neurologic examination Thoracic examination Abdominal examination Cardiac examination Musculoskeletal examination Soft tissue examination

Neurologic examination Inspected head and face Cranial nerves are tested Tympanic membrane inspected Spinal cord function Ability to move all extremities Ability to sense pain Spine should be palpated Peripheral nerve function Laceration Sacral and long bone fracture

Spinal cord injury in altered mental status patients : Priapism Diaphragmatic breathing Loss of rectal tone Absence of deep tendon reflex If spinal cord injury is diagnosed  high dose methylprednisolone

Thoracic examination Entire thorax : Adequacy and rate of respirations Seatbelt or other contusions should be inspected Ribs and sternum are palpated  bone crepitus, flail segment, subcutaneus emphysema Repeated chest radiography to confirm placement of endotracheal or thoracostomy tubes

Abdominal examination Possibility of intra abdominal injury : Complaints of abdominal pain Findings of ecchymosis or tenderness Other abdominal examination

The insertion of NGT and urinary bladder catheter insertion routine in multiple trauma patients Detection of gastric bleeding Decompression of the stomach Prevent vomitting and aspiration Safe performance of peritoneal lavage Contraindication : midface structure and CSF leakage

Folley catheter : After rectal and genitalia examination Detecting hematuria and for monitoring urine output Before DPL  decompress the bladder

Hematuria  renal injury Abdominal CT scan + contrast

Cardiac examination Heart rate , heart sounds, murmur, blood pressure, jugular venous pressure. ECG,Echocardiography Dysrythmia Myocardial depression Tamponade : Hypotension Elevated jugular venous pressure Muffled heart sounds

Musculoskeletal examination Identify fractures : Deformity, bone movement, crepitus, swelling, area of tenderness Check peripheral pulse and neurologic function Open fractures, hip/ knee dislocation  immediate definitive management

Soft tissue examination inspecting wounds, clearing gross decontamination, and applying dressings Tetanus immunization

Injured patients initial assessment

summary Examine first, anamnesis later Treat life-threatening condition first Primary survey : Airway-Breathing-Circulation Secondary survey : head to toe Definitive treatment

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