1. Patient Assessment during Influenza Epidemics Patient Assessment during Influenza Epidemics An Outline of the Approach to Patients An Outline of the Approach to Patients

2. Raymond L. Fowler, M.D., FACEP Associate Professor of Emergency Medicine and Co-Chair of the Section on EMS, Disaster Medicine, and Homeland Security -------------------- Chief of Medical Operations The Dallas Metropolitan BioTel System -------------------- Associate Professor of Emergency Medicine and Co-Chair of the Section on EMS, Disaster Medicine, and Homeland Security -------------------- Chief of Medical Operations The Dallas Metropolitan BioTel System --------------------

3. An immediate response is required to problems found during patient assessment An immediate response is required to problems found during patient assessment

4. For example, an obstructed airway can bring death in a matter of a couple of minutes For example, an obstructed airway can bring death in a matter of a couple of minutes

5. As we assess patients, we must quickly determine fundamental parameters of their respiratory and circulatory status. As we assess patients, we must quickly determine fundamental parameters of their respiratory and circulatory status.

6. Ray Fowler MD, FACEP Copyright 2006 Ray Fowler MD, FACEP Approaching the Patient Approaching the Patient

7. Ray Fowler MD, FACEP Copyright 2006 Ray Fowler MD, FACEP “See what you see!” “People look, but they don’t see” …A. Fowler, Jr. “People look, but they don’t see” …A. Fowler, Jr.

8. Ray Fowler MD, FACEP Copyright 2006 Ray Fowler MD, FACEP Alertness? Level of distress? Noises? Respirations? The pulse rate? Skin? Obvious things (bleeding) Alertness? Level of distress? Noises? Respirations? The pulse rate? Skin? Obvious things (bleeding)

9. Ray Fowler MD, FACEP Copyright 2006 Ray Fowler MD, FACEP History Taking: This seems to be a “lost black art” for so many medical providers What happened? When? LOC? Major system symptoms? Co-morbid conditions? Above all: RISK??? History Taking: This seems to be a “lost black art” for so many medical providers What happened? When? LOC? Major system symptoms? Co-morbid conditions? Above all: RISK???

10. Techniques of Patient Assessment Techniques of Patient Assessment Primary Survey Secondary Survey Third Survey Primary Survey Secondary Survey Third Survey

11. Scene Survey/Mechanism/# pts. LOC/Airway/Cspine Respiratory Rate and Labor Pulses R & Q, N & W Skin CMT/CRT/External Bleeding Pulses R & Q, N & W Skin CMT/CRT/External Bleeding Neck appearance, JVD, Trachea Chest appearance, BS, HT Quick survey of abdomen, pelvis, extremities, and back Quick survey of abdomen, pelvis, extremities, and back The Primary Survey Abbreviations: R & Q – Rate and Quality N & W – Neck and Wrist CMT – Color, Moisture, Temperature CRT – Capillary Refill Time JVD – Jugular Venous Distension BS – Breath Sounds HT – Heart Tones Abbreviations: R & Q – Rate and Quality N & W – Neck and Wrist CMT – Color, Moisture, Temperature CRT – Capillary Refill Time JVD – Jugular Venous Distension BS – Breath Sounds HT – Heart Tones

12. Scene Survey/Mechanism/# pts. LOC/Airway/Cspine Respiratory Rate and Labor Pulses R & Q, N & W Skin CMT/CRT/External Bleeding Neck appearance, JVD, Trachea Chest appearance, BS, HT Quick survey of abdomen, pelvis, and extremities Scene Survey/Mechanism/# pts. LOC/Airway/Cspine Respiratory Rate and Labor Pulses R & Q, N & W Skin CMT/CRT/External Bleeding Neck appearance, JVD, Trachea Chest appearance, BS, HT Quick survey of abdomen, pelvis, and extremities Reveals threats to Basic Physiology Reveals threats to Basic Physiology...the vital elements of the Primary Survey

13. The Order of the Survey 1 1 2 2 3 3 4 4 5 5 …flows in an orderly way from head to toe

14. Head Neck Upper Extremities Chest Abdomen Pelvis Lower Extremities The Secondary Survey

15. LOC Airway Breathing Circulation Any other pertinent positive or negative found in the primary or secondary surveys Any other pertinent positive or negative found in the primary or secondary surveys The Third Survey For example, if wheezing was found and treated in the primary survey, is the wheezing still there? If external bleeding was found and a dressing put on it, is the bleeding still stopped? For example, if wheezing was found and treated in the primary survey, is the wheezing still there? If external bleeding was found and a dressing put on it, is the bleeding still stopped?

16. Influenza A viral illness producing primarily a respiratory illness with fever, coughing, headache, muscle aches, and sometimes GI Sx A viral illness producing primarily a respiratory illness with fever, coughing, headache, muscle aches, and sometimes GI Sx

17. Influenza usually produces a mild to moderate illness Influenza usually produces a mild to moderate illness Either... Cough and feverCough and fever Severe myalgias & HASevere myalgias & HA GI SymptomsGI Symptoms CoughCough and fever SevereSevere myalgias & HA GIGI Symptoms Or a combination of any of these Or a combination of any of these

18. Pandemic Influenza A small percent of patients develop much more severe signs and symptoms A small percent of patients develop much more severe signs and symptoms

19. Pandemic Influenza Hemorrhagic pneumonia Encephalitis Severe GI symptoms Hemorrhagic pneumonia Encephalitis Severe GI symptoms

20. Hemorrhagic Pneumonia Profound shortness of breath Cyanosis and low pulse ox Severe coughing Bloody cough Respiratory failure Profound shortness of breath Cyanosis and low pulse ox Severe coughing Bloody cough Respiratory failure

21. Encephalitis Fever Headache Altered mental status, confusion Delirium Fever Headache Altered mental status, confusion Delirium

22. Gastrointestinal Nausea and vomiting Diarrhea Bloody diarrhea Abdominal pain Nausea and vomiting Diarrhea Bloody diarrhea Abdominal pain

23. Evaluating the Influenza Patient Evaluating the Influenza Patient FIRST PROTECT YOURSELF FIRST PROTECT YOURSELF

24. Evaluating the Influenza Patient Evaluating the Influenza Patient Primary Survey Secondary Survey Third Survey Primary Survey Secondary Survey Third Survey

25. Evaluating the Influenza Patient Evaluating the Influenza Patient Altered LOC? Respiratory distress? Nature of sputum? Blood pressure? Nature of any vomitus? Nature of any diarrhea? Altered LOC? Respiratory distress? Nature of sputum? Blood pressure? Nature of any vomitus? Nature of any diarrhea?

26. Evaluating the Influenza Patient Evaluating the Influenza Patient *Possible encephalitis - Altered LOC? *Possible encephalitis *Viral pneumonia or - Respiratory distress? *Viral pneumonia or secondary infection *Hemoptysis? - Nature of sputum? *Hemoptysis? *Shock? - Blood pressure? *Shock? *Bloody? - Nature of any vomitus? *Bloody? *Bloody? - Nature of any diarrhea? *Bloody? *Possible encephalitis - Altered LOC? *Possible encephalitis *Viral pneumonia or - Respiratory distress? *Viral pneumonia or secondary infection *Hemoptysis? - Nature of sputum? *Hemoptysis? *Shock? - Blood pressure? *Shock? *Bloody? - Nature of any vomitus? *Bloody? *Bloody? - Nature of any diarrhea? *Bloody?

27. Managing the Influenza Patient Managing the Influenza Patient *Sedation, ?airway, - Altered LOC? *Sedation, ?airway, treat infection? treat infection? *Respiratory support, - Respiratory distress *Respiratory support, treat infections? *Circulatory support - Shock *Circulatory support *Volume support - Vomiting and diarrhea *Volume support *Sedation, ?airway, - Altered LOC? *Sedation, ?airway, treat infection? treat infection? *Respiratory support, - Respiratory distress *Respiratory support, treat infections? *Circulatory support - Shock *Circulatory support *Volume support - Vomiting and diarrhea *Volume support

28. Signs of Shock Weak, thirsty, lightheaded Pale, then sweaty Tachycardia Tachypnea Diminished urinary output Weak, thirsty, lightheaded Pale, then sweaty Tachycardia Tachypnea Diminished urinary output Hypotension Altered LOC Cardiac arrest Death Hypotension Altered LOC Cardiac arrest Death Early Late

29. Synthesis

30. A influenza pandemic will present one of the greatest challenges to social and medical infrastructure ever seen A influenza pandemic will present one of the greatest challenges to social and medical infrastructure ever seen

31. Local, State, and National Preparedness are Essential… Local, State, and National Preparedness are Essential… …if we are to be able to make a difference… …if we are to be able to make a difference…

32. Drop a line if you have any questions or comments Drop a line if you have any questions or comments

33. drray@doctorfowler.com www.utsw.ws “the emergency medicine education website” www.utsw.ws