AJ Allen Submitted 2015-11-18
Emergency medicine is about assessing the urgent from the emergent in order to ensure that a life threatening event is stabilized and survives. Elements of both diagnostic and acute critical care allow the physician to make split second decisions based not only on what the physician knows from practice but evidence based care. Triaged patients and assigned with chief complaint that should generate a top 3 diagnostic list before entering the room. The Chief complaint is a combination of not only what the patient describes in the waiting room but the high probability conclusion by the listener. Upon entering the room, most of the information obtained stems from open ended questions that are based on the underlying problem that supports the chief complaint. A series of rule out questions allow the diagnostician to narrow in on the underlying mechanism behind the chief complaint that with confirmation will direct both future information gathering and a focused physical exam. The physician usually with a brief note card outlines the Chief complaint, History of present illness with events leading up to and following, loss of consciousness, injuries, past medical history including the major players of blood pressure, atherosclerosis, diabetes, arrhythmias, heart attack should be addressed as the may be recurrent and constant cause of return to the emergency room. In addition to medications that may address the aforementioned risk factors ensuring critical compliance and ensuring that prescriptions are filled and not a source of relapse. Underlying allergies (seasonal or otherwise) are addressed which can result in respiratory issues: asthma, emphysema, COPD exacerbated in smokers. Adjusting the priority of your chief complaint diagnostic list after a focused physical exam occurs with the following: site (i.e. location the quadrant upper/ lower), onset, duration, aggravating and alleviating factors, and previous episodes. From there you consult the attending and present the most pertinent details deciding whether there is a life threatening situation that should be dealt with immediately. Discussion of the patient’s case with the attending involves comparing the presented information collected, presented and processed with an experienced knowledge base. The critical step of separating the urgent from the emergent can occur. The highest likelihood now at the top of the diagnostic list, diagnostics tests will begin along with management. The order which includes: labs - cbc with differential (to address fever, infection, anemia), urinalysis (for intoxication, uti, stones), and imaging (ultrasound, x ray, CT). In addition to these confirmatory tests determine if any procedures need to occur to obtain fluid like a thoracentesis, paracentesis, or LP to determine pleural fluid/ LDH transudate vs exudate, ascites, or opening pressure for CSF infection/inflammation.
When the ambulance and EMTs are on their way you prepare based of the type of Injury motor vehicle vs motorcycle accident and whether there was a loss of consciousness or the individual had impact with the ground. Most of the information can be relayed over walkie- talkie. As soon as they arrive you begin the assessment from head to toe using the ABCDE (airway, breathing, cardiovascular, disability (i.e. blunt trauma and penetrating), exposure, and fracture. You get a brief report from the EMT especially if the patient is unconscious on arrival to determine the timing and onset of events also to be a made aware of primary injuries and blood loss. Assessment of the head for trauma include: facial laceration, checking pupil reaction, battle signs for otorrhea, rhinorrhea (for emergent CT algorithm i.e. CT without contrast to assess for emergent bleed), airway assessment with mallampatti obstruction intubation and ambo bag to assist with breathing. This assessment occurs simultaneously with the person at the head of the bed communicating with the team to do a spinal assessment for stability which may require a Miami J collar, turning the patient to one side for spine assessment and checking vertebrae. Observing the chest for any paradoxical breathing for pneumothorax (i.e. tension or spontaneous based on collision and patient body frame). Central line via the IJ/femoral may be needed and chest tube placement required. At this point if pain control was an issue decide if anesthesia is required with etomidate/ succinylcholine to stabilize the patient for continued assessment from the chest down and have the patient put on monitor for cardiac activity, pulse rate and oxygen. If oxygenation is still hypoxia, obtain arterial blood gases and a make a decision of PEEP (positive end expiratory pressure for increased alveolar recruitment). Ventilation to oxygenation ratio can be assessed with Stat IVs usually being put in place by the team under direction of the lead physician directing the trauma protocol. The FAST (focused abdominal ultrasound) can be brought in from the side of the bed to obtain an initial view of the abdomen where most the blood loss will coalesce, focusing on liver and spleen for rupture, with damage evaluation on of the kidneys bilaterally. If the patient remains tachycardia obtain EKG for confirmation with cardiac enzymes and including CK-MB. If pericarditis is present consider transthoracic echo with subsequent thoracotomy if patient is in the golden hour. If hypotensive consider origin of shock (i.e. hypovolemic, cardiogenic, vasogenic, and neurogenic) which will require fluid saline, RBC’s, and platelets. If a code occurs at any time rely on the trusted algorithms that incorporate medication reversal of dysrhythmias in coordination with CPR. Pelvic exam for skin discoloration, purpura or petechiae can determine a hip or pelvic fracture that may damage the bladder resulting in rupture/ obstruction which can be evaluated via ultrasound. Foley catheter may be introduced to check for blood, stones, infection, or damaged urethra. After that assess limbs for immobility, instability, or asymmetry which could indicate fracture. Fractures are reset at beside with casting, weighted pulley system, or external fixation. With head to toe assessment completed the injury can be addressed in a multidisciplinary approach where not only the location but the severity of the injury will decide the order of which teams are present: neurology/ neurosurgeon, ENT/ plastics, trauma, orthotrauma and the spatial orientation in which they treat the patient.