Approaching an acutely ill

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by Dr. Ihab Tarawa, Consultant Physician, Soba University Hospital

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  • To do so, the clinician must not only retain information, organize the facts, and recall large amounts of data but also apply all of this to the patient.
  • To do so, the clinician must not only retain information, organize the facts, and recall large amounts of data but also apply all of this to the patient.
  • Approaching an acutely ill

    1. 1. Ihab B Abdalrahman, MBBS, MD, ABIM, SSBBAssistant Professor of MedicineConsultant of acute Care Medicine Introduction to Emergency Medicine Ihab Tarawa 11/29/2012 1
    2. 2. Emergency An emergency is a situation that poses an immediate risk to:  health,  life,  property,  environment. Ihab Tarawa 11/29/2012 2
    3. 3. Most emergencies require urgent interventionto prevent worsening of the situation.. Ihab Tarawa 11/29/2012 3
    4. 4. Key emergency principle The key principles are:  assess the situation for danger.  observation of the surroundings, starting with the cause of the event. Ihab Tarawa 11/29/2012 4
    5. 5. Who should Help Ihab Tarawa 11/29/2012 5
    6. 6. Structured thought process Ihab Tarawa 11/29/2012 6
    7. 7. From what is inside, To the bedside Applying “book learning” to a specific clinical situation is one of the most challenging tasks in medicine. Ihab Tarawa 11/29/2012 7
    8. 8. • Retain information• organize the facts• recall large amounts of data Ihab Tarawa 11/29/2012 8
    9. 9.  It is challenging to apply these information in right contextCritical decisions Low resources Reassure Ihab Tarawa 11/29/2012 9
    10. 10. Backward Vs forward Traditional medicine Emergency Medicine We learn in one direction Anatomy Pathology Treatment Clinical Investigations applied Physiology Microbiology presentation lab & radiology pharmacology We receive patient in other direction Ihab Tarawa 11/29/2012 10
    11. 11. The presentation is notspecific Chest pain Cardiac Pulmonary Esophageal MI Embolism GERD USA Pneumothorax Spasm Pericarditis Pneumonia Ihab Tarawa 11/29/2012 11
    12. 12. The same disease my havedifferent presentation CP Weakness SOB MI Arrest Syncope Palpitation Ihab Tarawa 11/29/2012 12
    13. 13. Ihab Tarawa 11/29/2012 13
    14. 14. Traditional medicine Chief complaint HPI System review PMH FH SH DH Ihab Tarawa 11/29/2012 14
    15. 15. Examination Vital General Systems  CVS  Chest  Abdomen  Genital  Legs  CNS Ihab Tarawa 11/29/2012 15
    16. 16. lab & radiology CBC RFT LFT CXR US CT ECG MRI Ihab Tarawa 11/29/2012 16
    17. 17.  What about emergency medicine Ihab Tarawa 11/29/2012 17
    18. 18. APPROACH TO CLINICAL PROBLEM-SOLVING There are typically five steps that an ED clinician undertakes to systematically solve most clinical problems: Ihab Tarawa 11/29/2012 18
    19. 19. Following the patient’s response to the treatment Treating based on the stage of the disease Assessing the severity of the disease Making the diagnosisAddressing the ABCs and other life-threatening conditions Ihab Tarawa 11/29/2012 19
    20. 20. Emergency Assessment andManagement Patients often present to the ED with life- threatening conditions that necessitate simultaneous evaluation and treatment. Ihab Tarawa 11/29/2012 20
    21. 21. Pneumothrax CHF PE O2 C lab SOB X R Asthma Vent Pneumonia Ihab Tarawa 11/29/2012 21
    22. 22.  a comatose multi-trauma patient first requires intubation to protect the airway. Ihab Tarawa 11/29/2012 22
    23. 23.  A tensionpneumothoraxneeds animmediateneedlethoracostomy. Ihab Tarawa 11/29/2012 23
    24. 24. Ihab Tarawa 11/29/2012 24
    25. 25. Take home CLINICAL PEARL Because emergency physicians are faced with unexpected illness and injury, they must often perform  diagnostic and simultaneously.  therapeutic steps Ihab Tarawa 11/29/2012 25
    26. 26. Take home Step # 1 ABC In patients with an acute life-threatening condition, the first and foremost priority is stabilization— the ABCs. Ihab Tarawa 11/29/2012 26
    27. 27.  A airway is open Breathing Circulation Ihab Tarawa 11/29/2012 27
    28. 28.  Determination ofbreathlessness. The rescuer“looks,listens, andfeels” for breath. Ihab Tarawa 11/29/2012 28
    29. 29.  Head tilt Chin lift Ihab Tarawa 11/29/2012 29
    30. 30. Jaw-thrustmaneuverlift themandibleupwardwhilekeeping thecervicalspine inNeutral position Ihab Tarawa 11/29/2012 30
    31. 31. Ihab Tarawa 11/29/2012 31
    32. 32. Chest compressionsRescuer applyingchest compressionsto an adult victim Ihab Tarawa 11/29/2012 32
    33. 33. Step 2making a diagnosis Once the ABCs and other life-threatening conditions are stabilized, a more complete history and head-to-toe physical exam should follow Ihab Tarawa 11/29/2012 33
    34. 34. Step 2making a diagnosis This is achieved by:  carefully evaluating the patient,  analyzing the information,  assessing risk factors,  and developing a list of possible diagnoses (the differen-tial). Ihab Tarawa 11/29/2012 34
    35. 35. Step 2making a diagnosis Ihab Tarawa 11/29/2012 35
    36. 36.  Usually a long list of possible diagnoses can be pared down to a few of the most likely or most serious ones, based on the clinician’s knowledge, experience, and selective testing. Ihab Tarawa 11/29/2012 36
    37. 37. Step 3Assessing the Severity of theDisease After establishing the diagnosis, the next step is to characterize the severity of the disease process. Ihab Tarawa 11/29/2012 37
    38. 38. Assessing the Severity of theDisease Formal staging may be used  For example, the Glasgow coma scale is used in patients with head trauma. Ihab Tarawa 11/29/2012 38
    39. 39.  43 year Female Supra pubic pain for 2 days Dysuria and fever, Loin pain HR 80, BP 116/70, RR 18, Sat 98% Ihab Tarawa 11/29/2012 39
    40. 40.  70 year Female Supra pubic pain for 2 days Dysuria and fever, Loin pain Diabetic HR 110, BP 100/50, RR 28, Sat 98% Ihab Tarawa 11/29/2012 40
    41. 41.  70 year Female Supra pubic pain for 2 days Dysuria and fever, Loin pain Diabetic HR 156, BP 70/50, RR 44, Sat NA% Ihab Tarawa 11/29/2012 41
    42. 42. Take home The third step is to establish the severity or stage of disease. This usually impacts the treatment and/or prognosis. Ihab Tarawa 11/29/2012 42
    43. 43. Scenario Ca, healthy 56 Y male with HTN, DM smoker. Presented with CP. ECG STEMI 78 male with stage 4 Ca lung on NGT feeding, developed SOB. ECG STEMI Ihab Tarawa 11/29/2012 43
    44. 44. Step 4Treating Based on StageMany illnesses are characterized by stage or severity because this will affects prognosis and treatment. Ihab Tarawa 11/29/2012 44
    45. 45. Step 5Following the Response to Treatment The final step in the approach to disease is to follow the patient’s response to the therapy. Some responses are clinical such as improvement (or lack of improvement) in a patient’s pain. Ihab Tarawa 11/29/2012 45
    46. 46. Following the Response to Treatment Other responses may be followed by testing (e.g., monitoring the anion gap in a patient with diabetic ketoacidosis). Ihab Tarawa 11/29/2012 46
    47. 47. Following the Response to Treatment The clinician must be prepared to know what to do if the patient does not respond as expected. Treat again Reassess Not responding Different test Consult Ihab Tarawa 11/29/2012 47
    48. 48. CLINICAL PEARL The fifth step is to monitor treatment response or efficacy. This may be measured in different ways:  Symptomatically  based on physical examination  other testing. Ihab Tarawa 11/29/2012 48
    49. 49. Key parameter in ER For the emergency physician,  the vital signs,  oxygenation,  urine output,  and mental status . Ihab Tarawa 11/29/2012 49
    50. 50. SUMMARY There are five steps in the clinical approach to the emergency patient:  addressing life-threatening conditions,  making the diagnosis,  assessing severity,  treating based on severity,  and following response. Ihab Tarawa 11/29/2012 50
    51. 51.  Thanks Ihab Tarawa 11/29/2012 51
    52. 52. Ihab Tarawa 11/29/2012 52
    53. 53. ABCDE APPROACH Ihab Tarawa 11/29/2012
    54. 54. How to recognize critically ill patients Ihab Tarawa 11/29/2012
    55. 55. Learning Objectives -How to recognize a critically ill patient early. -How to identify and treat patients at risk of cardio respiratory arrest using ABCDE approach. Ihab Tarawa 11/29/2012
    56. 56. Medical emergency team calling criteria: Acute Change in: Physiology: Airway: Threatened Breathing: All respiratory arrest RR < 5/min or > 36/ min Circulation: All cardiac arrest Pulse rate < 40/min or > 140/min Systolic BP < 90 mmHg Neurology: Sudden decrease in level of consciousness Decrease of GCS of > 2 points Repeated or prolonged seizures Others: Any concern doesn’t fit above criteria Ihab Tarawa 11/29/2012
    57. 57. Principles of management Assess Monitor Manage Ihab Tarawa 11/29/2012 57
    58. 58. Underlying principals:2.Treat life threatening conditions beforemoving to next step of assessment.3.Call for help early.4.Reassess regularly.5.The aim is to keep patients alive andachieve clinical improvement as an initialstep for full management. Ihab Tarawa 11/29/2012
    59. 59. Ensure personal safety then check response If patient appear If appearsawake ask (how are unconscious , shake you?) and obtain and shout (are you brief Hx alright?)- Patent airway- Breathing Normal response No response- Maintainedcerebral circulation Complete ABCDE Complete ABCDE ALS Algorithm approach approach Ihab Tarawa 11/29/2012
    60. 60. Airway:- Signs of airway obstruction (partial-complete).- Treat as (medical emergency) * airway opening maneuvers * Simple airway adjuncts. * expert help for definitive airwaymanagement (endotracheal intubation)-Give O2 using a face mask ( initially 10 L/min) Ihab Tarawa 11/29/2012
    61. 61. Head Tilt & chin lift Jaw Thrust Ihab Tarawa 11/29/2012
    62. 62. Ihab Tarawa 11/29/2012
    63. 63. Breathing:Aim: Exclude and treat life threateningconditions.-pulmonary edema, acute severe asthma, tensionpneumothorax, massive hemothorax, PE.-Assess: simple chest examination ( inspection, palpation, percussion, auscultation)-Treat any problem encountered.-Monitor: pulse oximeter (O2 saturation)-Note : if O2 saturation < 94% --» increaseO2 flow to 15 L/min. Ihab Tarawa 11/29/2012
    64. 64. Circulation:-Assess: *pulse (all characteristics) *BPIf compromised: Hypovolemic shock until provedotherwise.-Manage: 2 wide bore canulae, draw blood forroutine ( CBC, RFT, LFT, RBG, Blood grouping and cross matching) special (e.g. Cadiac enzymes) Take arterial sample for ABG*infuse IV 1 L crystalloid if hypotensive 500 ml crystalloid in normotensive 250ml crystalloid in cardiac patients. Ihab Tarawa 11/29/2012
    65. 65. Monitor: by attaching the monitor(assess & treat tachycardias and bradycardias)-ask for 12 lead ECG if needed and consider early consultation. Ihab Tarawa 11/29/2012
    66. 66. Disability:Common causes of unconsciousness:-Profound hypoxia, hypercapnia, cerbral hypoperfusion,sedativesAssess: - AVPU scale for consciousness level - examine pupils (size, equality, reactivity to light) - use glucometer for bed-side blood glucose level →toexclude hypoglyceamia. -if below 3 mmol/ L → 50 ml of 10% DextroseNotes:*review patient drug chart*nurse unconscious patient in lateral position if airwayis not secured. Ihab Tarawa 11/29/2012
    67. 67. Exposure:With respect to patient dignity andminimizing heat loss, expose the patient’sbody fully for assessment (rash, hemorhage,DVT,….etc.) Ihab Tarawa 11/29/2012
    68. 68. REASSES AGAIN Ihab Tarawa 11/29/2012
    69. 69. The ABCDE approachAirway Circulation Assess patency, PR, BP, Capillary refill time. Open airway Manage accordingly Maintain patency, Attach to rhythm Monitor Consider definitive airway DisabilityBreathing Pupils Assess breathing Glucose check Manage and give O2 AVPU scale Monitor by pulse oximeter & Exposure ABGs Fully exposure & examination Ihab Tarawa 11/29/2012
    70. 70. QUESTIONS Ihab Tarawa 11/29/2012
    71. 71.  Thank you Ihab Tarawa 11/29/2012 71

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