Emergent Assessment

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Emergent Assessment

• Heather Hull, ARNP
• Karen Hayes, PhD, ARNP

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Emergent Care Focus

• Most common emergent problems
• How to assess patients
• Primary survey
• Secondary survey
• Significant aspects of history physical
• Lab, X-ray other diagnostics

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Emergent Care

• Emphasis is on diagnosis, not therapy
• In assessment of acutely ill patients, time is a
  critical factor
• Identifying the pathopysiologic abnormality is
  key
• Most serious threat to life? Ruled out?
• Provide protection safety for examiner/provider

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Triage Systems

• Emergent
• Urgent
• Non-urgent

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Emergent

• Condition requires immediate medical attention
• Time delay is harmful to patient
• Disorder is acute potentially threatening to
  live function

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Urgent

• Condition requires medical attention within the
  period of a few hours
• There is possible danger to the patient if
  medical attention is not given
• Disorder is acute but not necessarily severe

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Non-urgent

• Condition does not require the resources of an
  emergency service
• Referral for routine medical care may or may not
  be needed
• Disorder is nonacute or is minor in severity

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Nature of Problem

• Trauma
• Surgical
• Medical
• Age related factors

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Trauma

• Leading cause of death in ages 1- 45
• Fourth leading cause of death for all ages
• 70 million people have non-fatal injuries each
  year
• Approximately 140 thousand trauma deaths per year

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Three peak times of death

• First hour Immediate or at scene
• Examples massive brain injuries, high spinal
  cord injuries, massive MI, ruptured aortic
  aneurysm
• Two hours post event Stabilized (by EMS) at ER
• Examples subdural epidural hematomas,
  pneumothorax, ruptured spleen, lacerated liver,
  fractured femur. Goal, ordinarily to further
  stabilize transport to ICU

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Three peak times of death

• Delay of days to weeks May be due to etiology or
  treatment outcome.
• Examples sepsis or multiple system failure.
• Treatment causes may be due to
• too much fluid replacement later pulmonary edema
• too little fluid replacement later renal failure

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Epidemiology Injury Mechanism

• Important in predicting type of injuries
• History of event from patient or EMS significant

13
Categories to Consider

• Mechanical/gravitational forces MVA, falls,
  firearms, machinery
• Thermal heat, fire
• Radiant Sun, nuclear
• Chemical Poisonings plant animal toxins,
  drugs
• Electrical wires, sockets, lightening
• Hypoxia asphyxiation, drowning, gases. Carbon
  monoxide poisoning

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Categories to Consider

• Kinetic forces
• energy transferred to body (greater force
  greater damage)
• Predicable Injuries
• acceleration/deceleration, penetrating, caliber
  of gun, velocity

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Common Injuries

• Car 43
• Pedestrian 10
• Cycle 20
• Falls 13

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Common Causes of Fatal Injury

• MVA 31.7
• Suicide 16.3
• Homicide 12.5
• Unknown 6.7
• Other 32.7

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Protective Devices Help Prevent Fatal Injuries

• Motor Cycle
• 60.4 Unprotected
• 19.7 Protected (helmets)
• 19.7 Unknown

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Protective Devices help Prevent Fatal Injuries

• Auto
• 64.4 Unprotected
• 27.2 Protected (seat belts, car seats, air
  bags)
• 8.5 Unknown

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Mechanical Forces Predictable Injuries

• EMS protocols require cervical immobilization
  back boards for trauma victims
• The medical decision to release from cervical
  immobilization is the greater medical decision

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MVA Important History

• Windshield Star
• Cephalohematomas, skull fractures, cervical spine
  injuries
• Steering wheel impact
• chest injuries, sternal rib fractures,
  pericardial tamponade
• Front seat
• patella femur fractures posterior dislocation
  of femur _at_ acetabulum
• Back seat
• hyperextension of neck cervical spine

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MVA Important History

• Children, facing forward
• head chest injuries, leg fractures
• Delayed air bag deployment
• inhalation of dust, contusions of chest

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MVA - Pedestrian History

• Adult Leg injuries expected on impact side
• Fractures
• tibia, fibula, femur on side of impact
• If thrown on hood
• head, neck, jaw, chest injuries
• If thrown off upper body hits pavement
• dislocation of shoulder
• If dragged by vehicle
• pelvic fractures

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MVA - Pedestrian History

• Child Waddells Triade (usually face car)
• Fractured femur
• either side of impact or bilateral
• Trunk injuries
• Contra lateral head injury

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Falls, Landing on Feet

• Compression of lumbar vertebrae
• Fractures of ankle, calcaneous

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Initial Assessment Assumption

• Cardiopulmonary arrest
• Unstable patient
• Primary survey
• Key vital functions
• Secondary survey
• Relate calmness

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Primary Survey

• Airway
• Breathing
• Circulation
• Brief Neurological

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Primary Survey

• A rapid survey to recognize an acutely ill
  patient
• Note any unusual appearance or behavior
• Breathing difficulties, clutching chest or
  throat, slurring of speech confusion, unusual
  odor to breath, sweating or diaphoresis, or
  uncharacteristic skin color (pale, flushed,
  cyanotic)

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Airway

• Ineffective breathing decreased LOC, cyanosis,
  chest wall asymmetry, accessory muscles, sucking
  chest wounds, tracheal shift, distended neck
  veins
• Patient (back board cervical collar)
• do not hyperextend neck
• Check for loose teeth, foreign objects
• Consider oral or nasal airway, intubation or
  cricothyroidotomy

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Breathing

• Most ERs provide 02
• 6L/NC or non-re-breathing mask at 100
• Check arterial blood gases
• Keep head neck immobilized, if trauma

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Circulation

• If skin is warm, dry normal color
• indicates adequate O2 flow to periphery
• In shock, peripheral blood centrally shunted
• skin changes are early indicators of hypovolemia
  or cardiogenic shock (low cardiac output),
  delayed capillary refill
• Key skin changes
• gray, mottled, or cyanotic, cold, diaphoresis
• Arterial bleeding

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Arterial Bleeding Shock

• Apply direct artery pressure (pulse points)
• Elevate, if not fracture
• IV
• large bore needle blood tubing
• IV fluids (warmed LR often the choice)
• Lab
• CBC, Chem, enzyme profiles, ABG, X-ray
  (especially C-spine)

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Shock Vital Signs

• BP by palpation for systolic measure
• Radial 80
• Femoral 70
• Carotid 60

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CNS Function

• Initially assess patients ability to respond
  appropriately to questions
• Overdose
• Drug screen, Narcan
• Diabetic coma
• Dextrose, accucheck

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CNS Function

• Eye opening
• Verbal response
• Motor response
• Pupil Responses

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CNS AVPU

• A - Alert
• V - Responds to verbal stimuli
• P - Responds to painful stimuli
• U - Unresponsive

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Open Chest Injuries

• Tension Pneumothorax
• Open Pneumothorax
• Flail chest
• Massive Hemothorax

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Tension Pneumothorax

• Air enters but cannot escape
• Tracheal shift toward uninjured side
• Distended neck veins
• Absent breath sounds expansion on affected side
• Severe respiratory distress, cyanosis
• Treatment
• Needle thoracostomy, 2nd ICS, MCL (followed by
  chest tube water-sealed drainage)

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Open Pneumothorax

• Sucking chest injury
• Air moves in out
• Respiratory distress
• Treatment Cover wound on 3 sides with non-porous
  dressing
• Chest tube water-sealed drainage 5th ICS, MAL
  (3-4 ICS, MCL)

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Flail Chest

• Paradoxical chest wall movement
• Rib fractures loss of chest wall integrity
• Treatment
• High flow O2, intubate, ventilator, IV fluids

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Spontaneous Pneumothorax

• Bleb ruptures
• Hypoxic dyspnea
• May seal itself
• May be insidious for degree of pneumothorax
• Treatment
• Chest tube water-seal drainage, O2

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Massive Hemothorax

• Blood inside chest cavity
• Dyspnea, without the other above 3
  characteristics
• Treatment
• Chest tube water-sealed drainage

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Secondary Survey

• Head-Toe survey
• Analyze injuries

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AMPLE

• A - allergies
• M - medications
• P - past medical history
• L - last meal

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Head, Neck, Skull, Face

• Soft tissue
• Bone deformities
• Step depressions
• Foreign material

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Contusions Cephalohematomas

• Epidural
• Arterial
• rapid (fractures of temporal or parietal skull)
• Subdural
• Venous
• slower

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Eyes

• Raccoon eyes
• Anterior fossa basilar skull fracture
• Le Fort Fractures
• I Top of maxilla
• II Through zygomatic arch
• III Inferior orbit of eye

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Eyes

• Optic disc
• EOMs
• Hyphema
• Lacerations
• Foreign bodies

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Ears

• Battles Sign
• Middle fossa or posterior basilar skull fracture
• Ecchymosis behind ears
• Check TM for blood
• Check for CSP

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Nose

• Check for CSF

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Jaw

• Bite down
• Clench

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Neck

• Crepitus
• Distended vessels

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Thorax

• Soft tissue
• Breathing
• Bony deformities
• Abdomen/flank pain
• Distention

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Abdomen Flank

• Distention
• Pain
• Kehrs sign
• Ecchymosis
• Cullen sign
• Grey Turner sign
• Pregnancy

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Pelvis Genitalia

• Soft tissue
• Bone deformities
• Bleeding (genitalia rectum)

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Extremities

• Sensory function
• Motor function
• Soft tissue injuries
• Fractures
• Strains sprains

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Pediatric Considerations

• Temperature elevations heat loss
• Respiratory distress
• Dehydration
• Neurological changes

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Geriatric Considerations

• Skin
• malignant changes, heat loss, decubitus
• HEENT
• skull trauma, temporal arteritis, polymyalgia
  rheumatica, carotid bruits, thyroid
• Eyes
• visual acuity, macular degeneration, glaucoma,
  cataracts
• Ears
• hearing, dizziness, cerumen

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Geriatric Considerations

• Chest Respiratory
• vital capacity, infection risk, kyphosis
• Cardiovascular
• Aortic dilatation, sclerotic valves, heart block
  or arrhythmias, HTN, MI
• Abdomen GI
• absorption hepatic flow changes,
  diverticulosis, increased half-life of meds

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Geriatric Considerations

• GU
• Renal flow glomerular filtration change
• Endocrine
• diabetes, thyroid, fluid balance
• Musculoskeletal
• muscle atrophy, osteoarthritis, falls
• Neurologic
• atherosclerosis multiple infarcts, TIAs,
  dementia, delirium, depression, less reflexes

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Geriatric Considerations

• Altered presentation of disease
• Nonspecific presentation of disease
• Underreporting
• Multiple conditions
• Polypharmacy
• Chief complaint (variations)