Welcome to the Emergency Medicine Course.
I'm gonna start off by talking about the approach
to the undifferentiated patient in the Emergency Department.
So the first question you wanna ask yourself
when you see a patient in the ED is,
is this patient sick or are they not sick?
If your patient is sick,
you know that you need to act quickly
in order to get the situation under control.
So first and foremost, you're gonna get help,
especially if you are relatively a Junior Trainee,
you wanna make sure that you have some back-ups
so you could take good care of the patient.
You wanna also prioritize your sick patients
over your not sick patients.
Clearly, the ones who have life threat
should get cared for first.
You wanna rapidly assess the patient
so you could get to the bottom of what’s going on,
but you wanna simultaneously stabilize them at the same time
as you're treating them,
so that you can start making them feel better
and decrease the likelihood
that they're gonna have a bad outcome.
And you wanna expedite their diagnostic work up.
So when somebody is sick,
you really wanna get to the bottom of what’s going on
as quickly as you possibly can.
When we assess the acutely ill patient,
we’re gonna start off with the goal of identifying
and treating immediate life threats.
That’s gonna be the mantra we repeat to ourselves
while we're taking care of this patient.
And we’re gonna accomplish that by performing
an A-B-C-D assessment, on each and every patient,
each and every time.
Whenever somebody's sick, we wanna say, “OMI.”
That stands for oxygen, monitor, and IV access.
Oxygen, obviously to help with breathing,
monitor, so we can keep tabs on what's going on with the patient,
and IV access, so we can treat them if they need it.
Like I mentioned before,
the goal with sick patient
is simultaneous assessment and treatment
so while we are assessing our patient,
if we identified a life threat,
we don’t wannna just keep going along in assessing them,
we wanna address that life-threat immediately.
This is not the time to sit down and take a leisurely history
and perform a physical exam
and then start thinking about treatment.
We need to be able to do everything all at once
to get the ball rolling for our patient
and get them stabilized as rapidly as we can.
So we’re gonna start off talking about the ABC assessment,
and as you've probably heard before,
ABC stands for airway, breathing, and circulation.
When we think about the airway,
clearly, anybody who's talking, that's a good sign.
They have a patent airway.
But even for a patient who is able to speak and phonate normally,
they could possibly have future airway obstruction
and we wanna be prepared to deal with that.
So look for signs of edema either on the face or the pharynx.
Look for blood, vomit, or other foreign material in the airway
and listen to their breathing.
Not with a stethoscope but just with your naked ear.
Anytime a patient is breathing in a way that’s noisy
or easily audible, that’s obstructed breathing,
and the louder it is, the more concerned that you should be.
Regarding breathing, the best thing we can do
is just get a Gestalt sense
of how hard the patient is working to breathe.
If the patient is using the muscles in their neck
and in their chest,
and if they're doing push-ups when they try to breathe,
those are all signs
that they could potentially have impending respiratory failure
coz they're not gonna be able to maintain that high level
of work of breathing indefinitely.
We wanna listen to their breath sounds,
and we wanna check their pulse ox.
The pulse ox
is the single most important vital sign for breathing.
The whole purpose of the lungs
is to get oxygen into the blood stream
and even if the patient looks and sounds great,
if they are hypoxic, you’ve got a problem with B.
Lastly, we wanna check circulation.
So part of circulation
is just to general Gestalt look at the patient.
If the patient is maintaining well, and they're nice and pink,
that’s a really good sign that they're perfusing their brains
and the rest of their bodies adequately.
Whereas if they are pale, cyanotic, altered,
they may potentially not be perfusing as well as we’d hope.
We also wannna feel peripheral pulses.
Now clearly, a patient who's awake and talking to you,
obviously has a carotid pulse, right?
They must be perfusing their brain.
But if they have a weak or absent peripheral pulse,
that's something that we wanna be aware of
coz that could tell us potentially
that they are not perfusing the periphery as well as we'd hope.
We also wanna look at their vital signs.
The heart rate, the cardiac rhythm, the blood pressure,
these all give us important clues
about the adequacy of circulation.
So let's start off with A and B.
Now A and B are usually assessed together
and the vast majority of A and B problems
are really B problems.
They're usually caused by pulmonary disease
rather than primary airway emergencies,
although we do look at the two things together.
respiratory rate is an important vital sign for A and B.
A patient who's breathing very quickly,
you wanna be concerned about the possibility
that they're gonna tire out
and not be able to sustain that respiratory rate.
I also wanna mention that respiratory rate
is often not documented correctly in the chart,
so this is one that you should really check yourself.
You should bust out your watch, look at the patient,
count their respirations over the course of a minute,
so that you can get a really good sense
of how quickly they're breathing.
Pulse ox, we already mentioned is absolutely critical
it's the most important vital sign for A and B,
and again, that work of breathing.
If a patient is using a lot of metabolic energy
to get air into their lungs,
they're not gonna be able to sustain that indefinitely.
Meaning, that they're gonna be able to
continue oxygenating and ventilating normally in the long run.
And they're at risk for developing respiratory failure.
Anytime you suspect a problem with A and B,
you wanna start off by giving them high flow oxygen
that’s gonna obviously address hypoxia
and hopefully also reduce their work of breathing
coz they'll be able to oxygenate with less effort.
You wanna be ready to manage the airway.
That’s not to say
that every single patient needs to be entubated right this minute
but you wanna have the necessary equipment,
medications, and personnel available,
so that if you do need to manage the airway, you’ll be ready.
You wanna auscultate the lungs
and that’s really important because
auscultation doesn’t tell you
if there's a problem with airway and breathing
but it can help tell you why.
It can help narrow your differential.
So if your patient is wheezing,
you're gonna manage them differently than if they have crackles
versus if they have unilaterally absent breath sounds.
So different lung sounds are gonna help us understand
what the underlying problem is and treat it accordingly.
And then lastly, we wanna get a stat chest x-ray.
Any patient with any degree of respiratory distress
deserves to have a picture of their lungs
so we can get a better sense
of what's going on with them physiologically.
Let’s move on to C.
So we already mentioned some of the things we wanna check for C.
I wanna also stress the importance of vital signs
for circulatory assessment.
So anytime a patient is tachycardic,
there's one of two things going on.
Either A, they're having a cardiac dysrhythmia
and you wanna make sure that you address that rhythm disturbance
as a primary disease process,
or two, if they're in sinus tachycardia
so their cardiac rhythm is normal but their heart rate is fast,
then you wanna recognize
that they're trying to physiologically compensate
for some underlying derangement,
you wanna figure out what that derangement is
and take care of it .
Blood pressure is kind of like pulse ox, right?
It’s the bottom line on circulation,
it’s the bottom line for C.
The whole point of the circulatory system
is to send blood to the vital organs,
and if your blood pressure is low,
then the perfusion pressure for those vital organs
is gonna be low,
meaning that your circulation is inadequate.
So even for a patient with a normal heart rhythm and rate,
if they're hypotensive, we have a C problem
and we need to take care of it.
Anytime we suspect a problem with C,
we wanna make sure we get two large pore IV catheters.
Not one, but two.
And that's so important
because we wanna make sure that we have the ability
to rapidly infuse fluid or blood products if the patient needs it
and in the event that one of our IV’s infiltrates or falls out,
we wanna always have a back up
so that we're not facing interruptions or obstacles
in trying to treat our critically ill patient.
We wanna make sure that we get a good look at the monitor
and differentiate those patients
who have non-sinus from those who have sinus rhythms,
and again, if they have a non-sinus rhythm,
we wanna think about treating it.
And lastly, we wanna consider IV fluids.
Now, not every single patient
with a circulatory abnormality needs IV fluids
but the vast majority will benefit.
There are some cases like cardiogenic shock,
where the underlying problem is really pump failure.
The heart's not squeezing adequately to perfuse the body.
That’s a situation where fluid isn't gonna benefit you,
but in the vast majority of cases,
filling up the tank or optimizing intravascular volume
is gonna be the first step in stabilizing C.