clinical examination in emergency department. the objective 1. able to examine emergency cases...
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Clinical Examinationin
Emergency Department
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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
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The difference in managing an emergency patient
• Immediately do PRIMARY SURVEY first, anamnesis later
and
• Treat the life-threatening condition first
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• Emergency department :– Trauma patient– Non trauma patient
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Tri-modal Distribution of Death (Trankey)
Time after injuryTime after injury
11 22 33 4 hrs4 hrs
Perc
ent
of
traum
a d
eath
sPerc
ent
of
traum
a d
eath
s
1010
2020
3030
4040
5050
1-21-2 5-6 weeks5-6 weeks
IMMEDIATE: CNS injury, or heartIMMEDIATE: CNS injury, or heartand great vessel injuryand great vessel injury
EARLY: major hemorrhageEARLY: major hemorrhage
LATE: infection andLATE: infection andmulti organ failuremulti organ failure
I/R injuryInflammationTissue hypoxia
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• 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
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• 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
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Standard precautions
• Cap
• Gown
• Gloves
• Mask
• Shoe covers
• Goggles/face shields
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Triage
• Sorting of patients according to:– ABCDE’s : red, yellow,green– available resources
• Multiple casualties
• Mass casualties
• Adult/pediatric/pregnant women=priorities are the same
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• Physical examination in emergency patient – Primary survey :
• A,B,C,D,E,F
– Secondary survey :• Neurologic• Cardiac• Abdomen/pelvis• Musculoskeletal• Soft tissue
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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
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• 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.
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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
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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
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• Stabilizing the neck + jaw thrust maneuver
• Clear the oropharynx of debris
• Consider cervical cord injuries in all seriously traumatized patients
• OPEN, CLEAR, MAINTAIN
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Jaw thrust
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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.
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• Oxygenate immediately if :– Decreased level of consciousness– Shock– Severe hemorrhage– Chest pain– Chest trauma– Dyspnea– Respiratory distress– Multi- system trauma
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• 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
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• Respiratory failure ventilation assisted
• Initially : bag valve mask
• Excessive volume or rate gastric distension impair ventilation further
• Cricoid pressure may be usefull
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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
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• Airway management :– Orotracheal intubation– Nasotracheal intubation– Surgery : crycothyrotomy , etc– Fiberoptic intubation
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Intubation
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• 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.
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Tension Pneumothorax
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Circulation and hemorrhage control
• Circulation :– Is the heart beating ?– Is there serious external bleeding ?– Is the patient perfusing ?
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• Circulation :– Does patient have radial pulse ?
• Absent radial : systolic BP < 80
– Does patient have carotid pulse ?• No carotid pulse ?• CPR !!!!
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• External bleeding :– Direct pressure : hand, bandage
• All bleeding stops eventually
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• Is the patient perfusing ??– Cool, pale, moist skin– Capillary refill > 2 sec– Restlessness, anxiety, combativeness
• Internal hemorrhage ??– Expose, palpate abdomen, pelvis, thighs
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• Shock : prompt diagnostic and therapeutic intervention
• Treatment :– Improving perfusion by volume resuscitation
and inotropic– Control of any ongoing hemorrhage
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• IV LINE :– Peripheral vein large bore catheter– Venous cutdown– Large bore central line placement– Intraosseus line
• Choice of resuscitation fluid :– Crystalloid– Coloid– Blood
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Disability assessment (thorough neurologic examination)
• AVPU
• GCS
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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
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Disability assessment (thorough neurologic examination)
• GCS
• Eye opening response :– 4 : spontaneous– 3 : to verbal command– 2 : to pain– 1 : none
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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
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GCS : Glasgow Coma Scale
• Verbal response– 5 : Oriented and converses– 4 : Confused conversation– 3 : Inappropriate words– 2 : Incomprehensible sounds– 1 : None
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• Total score key :– Severe < 9– Moderate 10 – 13– Mild 14 – 15
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• Decreased of consciousness :– Brain injury– Hypoxia– Hypoglycemia– Shock
• NEVER think drugs, alcohol or personality first
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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
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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.
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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
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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
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Secondary survey
• Neurologic examination
• Thoracic examination
• Abdominal examination
• Cardiac examination
• Musculoskeletal examination
• Soft tissue examination
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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
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• 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
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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
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Abdominal examination
• Possibility of intra abdominal injury :• Complaints of abdominal pain• Findings of ecchymosis or tenderness
• Other abdominal examination
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• The insertion of NGT and urinary bladder catheter insertion routine in multiple trauma patients
• NGT :– Detection of gastric bleeding– Decompression of the stomach– Prevent vomitting and aspiration– Safe performance of peritoneal lavage– Contraindication : midface structure and CSF leakage
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• Folley catheter :– After rectal and genitalia examination– Detecting hematuria and for monitoring urine
output– Before DPL decompress the bladder
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• Hematuria renal injury
• Abdominal CT scan + contrast
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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
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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
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Soft tissue examination
• inspecting wounds, clearing gross decontamination, and applying dressings
• Tetanus immunization
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Injured patients initial assessment
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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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Thank you