1. Clinical Examination in Emergency Department

2. 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

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

4. Emergency department :
Trauma patient
Non trauma patient

5. 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

6. 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

7. 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

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

9. 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

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

11. 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

12. 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.

13. 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

14. 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

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

16. Jaw thrust

17. 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.

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

20. 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

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

23. 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

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

25. Intubation

27. 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.

28. Tension Pneumothorax

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

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

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

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

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

34. 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

35. Disability assessment (thorough neurologic examination)
AVPU
GCS

36. 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

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

38. 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

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

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

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

42. 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

43. 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.

44. 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

45. 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

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

47. 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

48. 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

49. 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

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

51. 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

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

54. Hematuria  renal injury
Abdominal CT scan + contrast

55. 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

56. 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

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

58. Injured patients initial assessment

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

60. Thank you