Clinical Examinationin

Emergency Department

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

The difference in managing an emergency patient

• Immediately do PRIMARY SURVEY first, anamnesis later

and

• Treat the life-threatening condition first

• Emergency department :– Trauma patient– Non trauma patient

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

• 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

• 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

Standard precautions

• Cap

• Gown

• Gloves

• Mask

• Shoe covers

• Goggles/face shields

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

• Physical examination in emergency patient – Primary survey :

• A,B,C,D,E,F

– Secondary survey :• Neurologic• Cardiac• Abdomen/pelvis• Musculoskeletal• Soft tissue

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

• 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.

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

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

• Stabilizing the neck + jaw thrust maneuver

• Clear the oropharynx of debris

• Consider cervical cord injuries in all seriously traumatized patients

• OPEN, CLEAR, MAINTAIN

Jaw thrust

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.

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

• 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

• Respiratory failure ventilation assisted

• Initially : bag valve mask

• Excessive volume or rate gastric distension impair ventilation further

• Cricoid pressure may be usefull

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

• Airway management :– Orotracheal intubation– Nasotracheal intubation– Surgery : crycothyrotomy , etc– Fiberoptic intubation

Intubation

• 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.

Tension Pneumothorax

Circulation and hemorrhage control

• Circulation :– Is the heart beating ?– Is there serious external bleeding ?– Is the patient perfusing ?

• Circulation :– Does patient have radial pulse ?

• Absent radial : systolic BP < 80

– Does patient have carotid pulse ?• No carotid pulse ?• CPR !!!!

• External bleeding :– Direct pressure : hand, bandage

• All bleeding stops eventually

• Is the patient perfusing ??– Cool, pale, moist skin– Capillary refill > 2 sec– Restlessness, anxiety, combativeness

• Internal hemorrhage ??– Expose, palpate abdomen, pelvis, thighs

• Shock : prompt diagnostic and therapeutic intervention

• Treatment :– Improving perfusion by volume resuscitation

and inotropic– Control of any ongoing hemorrhage

• IV LINE :– Peripheral vein large bore catheter– Venous cutdown– Large bore central line placement– Intraosseus line

• Choice of resuscitation fluid :– Crystalloid– Coloid– Blood

Disability assessment (thorough neurologic examination)

• AVPU

• GCS

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

Disability assessment (thorough neurologic examination)

• GCS

• Eye opening response :– 4 : spontaneous– 3 : to verbal command– 2 : to pain– 1 : none

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

GCS : Glasgow Coma Scale

• Verbal response– 5 : Oriented and converses– 4 : Confused conversation– 3 : Inappropriate words– 2 : Incomprehensible sounds– 1 : None

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

• Decreased of consciousness :– Brain injury– Hypoxia– Hypoglycemia– Shock

• NEVER think drugs, alcohol or personality first

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

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.

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

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

Secondary survey

• Neurologic examination

• Thoracic examination

• Abdominal examination

• Cardiac examination

• Musculoskeletal examination

• Soft tissue examination

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

• 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

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

Abdominal examination

• Possibility of intra abdominal injury :• Complaints of abdominal pain• Findings of ecchymosis or tenderness

• Other abdominal examination

• 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

• Folley catheter :– After rectal and genitalia examination– Detecting hematuria and for monitoring urine

output– Before DPL decompress the bladder

• Hematuria renal injury

• Abdominal CT scan + contrast

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

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

Soft tissue examination

• inspecting wounds, clearing gross decontamination, and applying dressings

• Tetanus immunization

Injured patients initial assessment

summary

• Examine first, anamnesis later

• Treat life-threatening condition first

• Primary survey : Airway-Breathing-Circulation

• Secondary survey : head to toe

• Definitive treatment

Thank you