Beruflich Dokumente
Kultur Dokumente
Emergencies
Carlos Primero Gundran, MD, MScDM, FPCEM
Consultant, Department of Emergency Medicine
UP-PGH
Objectives
• 1. How to Run a Code
• 2. Approach to the Unconscious Patient
• 3. Approach to a Hypotensive Patient
• 4. How to give Inotropes
• 5. Alcohol Intoxication
• 6. Seizures
• 7. Anaphylaxis
• 8. Other Common ER Cases (except OB
and Trauma
Vignette
• A. Clinical Case vignette ( hx, sigbs, and
symptoms short condensed form)
• B. How to Diagnose at the Level of a
Moonlighter
• C. How to Treat at the Level of a
Moonlighter
Is there a specific mindset
you should have during
Emergencies?
Initial Actions
• D angers
• R esponsiveness
• A irway
• B reathing
• C irculation
• D efibrillation
Priorities
Problems Primary Problems Secondary
Survey Survey
•A • Obstructed • HTCL/JT
•C • No Pulse • CC
•D • Shockable • Defibrillate
Secondary Survey
• Problem • Solution
•D • No Improvement • Differentials
Priorities
Problems Primary Problems Secondary
Survey Survey
Megacode
“Resuscitation Simulation Exercise”
15/37AUGUSTO A. TEODORO, JR., MD, DPBECP
Megacode
AW
ET: Electrical therapist ET
IV: IV therapist
CC: Chest Compressor
CC IV
16/37
17/37AUGUSTO A. TEODORO, JR., MD, DPBECP
18/37AUGUSTO A. TEODORO, JR., MD, DPBECP
NAME: AGE/SEX: DATE:
Resuscitation Sheet
EKG TIME VITAL SIGNS D IVF DRUG DOSE AND ROUTE ETC.
H M B P R T
E EPI AMI LID Mg BC AT
O I P R R F
U N I
R B
Ventricular Fibrillation 12 00 CPR
12 07 1
mg/IV
Ventricular Fibrillation
12 08 200 J CPR
RESUSCITATION TEAM
Team Leader: _______________________
Airway Specialist: _______________________
Electrical Therapist: _______________________
CPR Man: _______________________
IV Therapist:
19/37
_______________________
INSTRUCTOR:
Code Organization
• Phase I: Anticipation
• Phase II: Entry
• Phase III: Resuscitation
• Phase IV: Maintenance
• Phase V: Family Notification
• Phase VI: Transfer
• Phase VII: Critique
20/37
P1: Anticipation
21/37
P1: Anticipation
Necessary steps:
• Analyze initial data
• Assemble the RESUS team
• Identify the team leader
• Assign critical tasks
• Prepare and check equipments
• Position the team leader and team
members to begin resuscitation
22/37
23/37
P1: Anticipation
Check Defibrillator
• Battery charge
• Cables
• Electrodes
• Paddles
• Pads for TCP
• Gel
• ECG Paper
• Spare Defibrillator
24/37
P1: Anticipation
• Personal Protective Devices
• Protective eyewear
• Surgeon’s mask
• Gloves
• Gown
P1: Anticipation
26/37
P1: Anticipation
27/37
P1: Anticipation
Keep at least 1 resuscitation bed available
RESUS Team:
• Team leader
• Members:
• Airway Management
• CPR
• Defibrillation
• Vascular access and medication administration
29/37
P2: Entry
30/37
P3: Resuscitation
• Team leader:
• Be Decisive
• Be Professional
• Speak in a firm, confident tone
• Communicate observations to team
members
• Be open to and actively seek suggestions
from team members
• Focus on the ABCD of resuscitation
31/37
P3: Resuscitation
• Team Members
• State vital signs every 3 to 5 minutes or with any
change in ABCDs of resuscitation
• State when procedures and medications are
completed
• E.g., IV started – left antecubital vein
1 mg 1:10000 epinephrine given IV
• Clarify order as needed
• Prove primary and secondary ABCD information
32/37
Primary ABCD Survey
• Airway
• Breathing
• Circulation
• Defibrillation
33/37
Attach Monitor/Defibrillator
34/37
35/37
Lethal Rhythms
Pulse QRS Rhythm
Ventricular Wide
No pulse complex; Regular
tachycardia
opposite T
Wide
Ventricular Irregular
No pulse complex;
fibrillation
opposite T
Pulseless
Electrical No pulse Any
Activity
Asystole No pulse
36/37
Lethal Rhythms
Pulse QRS Rhythm
Ventricular Wide
No pulse complex; Regular
tachycardia
opposite T
Wide
Ventricular Irregular
No pulse complex;
fibrillation
opposite T
Pulseless
Electrical No pulse
Activity
Asystole No pulse
37/37
Lethal Rhythms
Pulse QRS Rhythm
Ventricular Wide
No pulse complex; Regular
tachycardia
opposite T
Wide
Ventricular Irregular
No pulse complex;
fibrillation
opposite T
Pulseless
Electrical No pulse
Activity
Asystole No pulse
P4: Maintenance
39/37
P6: Transfer
40/37
P7: Critique
41/37
Core Concepts
43/37
Apply different interventions
whenever appropriate
indications exist.
44/37
Adequate airway, ventilation,
oxygenation, chest compressions and
defibrillation are more important
than administration of medications
A
B
C
45/37
After each IV medication, give a 20 to
30 ml bolus of IVF and immediately
elevate the extremity
ormal
Lactated aline
Ringer’s
Solution
46/37
Conduct during Code
• Act professionally.
• Do not laugh during a code.
• Anticipate.
• Time and record everything.
• Treat the patient not the monitor.
47/37
How to Approach an
Unconscious Patient
Initial Approach
Gloria Ramirez, aged 31, died
• D- are there any dangers? of kidney failure in
California. The body was
taken to Riverside hospital,
and a doctor found that her
skin was covered in an oily
sheen. When her blood
sample was taken, everyone
felt some kind of fume
evaporation in the air. Her
blood sample was full of
strange white crystals.
Nothing was explained. And
all who were in contact with
her were affected. The doctor
suffered damage of the liver
and lungs, as well as bone
necrosis.
Check for Responsiveness
• Unresponsive • Responsive
• Call First • No need for CPR “yet”
• CPR First • Proceed to Secondary
• CPR/CABD Survey
Differential Diagnosis in 2’
Survey
Search for and treat possible contributing factors:
§Hypovolemia §Toxins
§Hypoxia §Tamponade, cardiac
§Hydrogen ion- acidosis §Tension pneumothorax
§Hyper-/hypokalemia §Thrombosis, cardiac
§Hypothermia §Thrombosis, pulmonary
§Hypoglycemia §Trauma
Causes of Altered Sensorium
• Arrhythmias • C
• Heart Attack • A
• Vasovagal • B
• Stroke • D
• Brain Neoplasms • Metabolic
• Head Injury
• Hypoglycemia
• Seizures
Causes of Altered Sensorium:
C
• Stroke/TIA
• Head Injury
• AMI
• CHF
• Ventricular
Arrhythmia
• Dehydration
Causes of Altered Sensorium:
A/B
• Stroke/TIA
• Head Injury
• Hypoxia
• Hypercarbia
Causes of Altered Sensorium:
D/Others
• Dementia • Hypothermia
• Delirium • Hepatic
• Seizures with post- Encephalopathy
ictal state • Uremia
• Depression • Acute Systemic
• Hyperglycemia Infection
• Hypoglycemia • Bipolar Disorder
• Electrolyte • Acute Psychosis
imbalance
Causes of Altered Sensorium:
D/Others
• Drug
Toxicity/Withdrawal
• Alcohol
Toxicity/Withdrawal
• Hip Fracture
• Pulmonary Embolism
Assessment
• AVPU
• GCS
• Lateralizing signs
• Sensory
• Motor
• Reflex
Case 1
• 50 year old male, unemployed
• Found this morning on the sidewalk
besides his house
• Carried and brought home by relatives
• Brought to your ER at 11pm
Case 1
• What is your Impression?
• What will be your Management?
Alcohol Intoxication
• Supportive: • Blood glucose
• IV D5 containing. detertmination
• B1: Thiamine • r/o other problems
(suspected • Diagnostics limited
malnutrition/ by finances.
starvation)
100mg/IV prior to
D50/50
• Multivitamin/IV
Case 2
• A 3 y/o male brought to the Emergency
Room by the grandmother because of
high grade fever and rigidity followed
by jerking of extremities.?
Seizures
• Priority Problems in Active Seizures
• Airway and Breathing
• Airway Adjuncts (OPA/NPA)
• Bite Guard
• Recovery position
• Suction ready
• Supportive and protective
• IV anticonvulsants (>5 mins)
Seizures
• With history of seizures
• Missed a maintenance dose?
• Determine anticonvulsant levels
• Refer to attending.
• Any precipitating conditions?
• Can you increase /adjust the maintenance?
• Make sure they will follow-up with attending
in 1-3 days
Seizures
• First unprovoked seizure
• Determine the etiology
• Admit: with identifiable underlying
condition
• Pregnancy >20wks, (HPN, edema, proteinuria)
• Discharge: N Neurologic examinations and
CT Scan, no acute/chronic medical
comorbidities, N mental status
Seizure Treatments
• Benzodiazepines
• MgSO4- for pre-eclampsia
• Correct underlying condition:
• Metabolic, infection, poisoning,
temperature
•x
Drug Dosage
• Diazepam
• 0.2mg/kg BW IV (10mg for a 50kg adult)
• Pedia: 0.2-0.5mg/kg IV q 15-30mins max
10mg
• Midazolam
• 0.07-0.2mg/kg BW IV (3.5-10mg for a 50kg
adult)
• Pedia: 0.4-0.5mg/kg, max 15mg
Drug Dosage
• Phenytoin
• 20mg/kg loading dose max 1000mg
(1000mg for a 50 kg adult).
Case 3
1. Body in advanced
stage of
decomposition
2. Injuries
incompatible with
Survival e.g.
Decapitation
3. Rigor mortis
4. Lividity
SURROGATE DECISION
MAKERS
• When a patient has lost the capacity to make
medical decisions, a close relative or friend
can become a surrogate decision maker for
the patient.
• Most states have laws that designate the legal
surrogate decision maker (guardian) for an
incompetent patient who has not designated
a decision maker through a durable power of
attorney for health care.
SURROGATE DECISION
MAKERS
The law recognizes the following order of priority
for guardianship in the absence of a previously
designated decision maker:
(1) spouse
(2) adult child
(3) parent
(4) any relative
(5) person nominated by the person caring for the
incapacitated patient
(6) specialized care professional as defined by law.
SURROGATE DECISION
MAKERS
Surrogates should base their decisions on:
• the patient’s previously expressed
preferences if known
• patient’s best interest
Death Certificate
• Accomplish the blue
form in
handwriting.
• Sequence of
arrangement: BLUE-
WHITE-BLUE-
BLUE
• Make sure the
recipients
acknowledges the
receipt of 3 forms
and sign the 4th
Medico-Legal
Death
• Death within 24 hours of
arrival to the hospital. (ER
and beyond).
• Suspicion of foul play,
victims of violence, sex
crimes, accidents, self-
inflicted injuries,
intoxications, addictions,
unidentified patients
• Never issue a death
certificate.
Disposition of Cadavers
(Medico-Legal Cases)*