welcome to the emergency medicine course
I'm going to start off by talking about
the approach to the undifferentiated
patient in the emergency department so
the first question you want to ask
yourself when you see a patient in the
IDI 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 going to
get help
especially if you're a relatively junior
trainee you want to make sure you have
some backups so you can take good care
of the patient you want to also
prioritize your sick patients over your
not sick patients clearly the ones who
have life threats should get cared for
first you want to rapidly assess the
patient so you can get to the bottom of
what's going on but you want to
simultaneously stabilize them at the
same time as you're treating them so
that you can start making them feel
about our and decrease the likelihood
that they're going to have a bad outcome
and you want to expedite their
diagnostic workup in management so when
somebody's sick you really want to get
to the bottom of what's going on as
quickly as you possibly can when we
assess the acutely ill patient we're
going to start off with the goal of
identifying and treating immediate life
threats that's going to be the mantra we
repeat to ourselves while we're taking
care of this patient and we're going to
accomplish that by performing an ABCD
assessment on each and every patient
each and every time whenever somebody's
sick we want to say oh my
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 patients is simultaneous assessment
and treatment so while we're assessing
our patient if we identify a life threat
we don't want to just keep going along
and assessing them we want to 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 page
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 paynton
airway but even for a patient who's able
to speak and phone eight normally they
could possibly have future airway
obstruction and we want to be prepared
to deal with that so look for signs of
edema either in 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 concern 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 because they're not
going to be able to maintain that high
level of work of breathing indefinitely
we want to listen to their breath sounds
and we want to check their pulse ox the
pulse ox is a single most important
vital sign for breathing the whole
purpose of the lungs is to get oxygen
into the bloodstream and even if the
patient looks and sounds great if
they're hypoxic you've got a problem
with B lastly we want to check
circulation so part of circulation is
just a general Gestalt look at the
patient if the patient is meant aning
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're
pale cyanotic altered they may
potentially not be profusing as well as
we'd hope we also want to feel
peripheral pulses now clearly a patient
who's awake and talking to you obviously
has a carotid pulse right they must be
profusing their brain but if they have a
weak or absent peripheral pulse that's
something that we want to be aware of
because that could tell us potentially
that they're not perfusing they're the
periphery as well as we'd hope we also
want to look at their vital signs the
heart rate the cardiac
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 so again
respiratory rate is an important Russ is
an important vital sign for a and B a
patient who's breathing very quickly you
want to be concerned about the
possibility that they're gonna tire out
and not be able to sustain that
respiratory rate I also want to 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 going to be able to
sustain that indefinitely meaning that
they're not going to be able to consider
I 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 want to start off by giving them
high flow oxygen that's going to
obviously address hypoxia and hopefully
also reduce their work of breathing
because they'll be able to oxygen
you want to be ready to manage the
airway that's not to say that every
single patient needs to be intubated
right this minute but you want to have
the necessary equipment medications and
personnel available so that if you do
need to manage the airway you'll be
ready
you want to 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 going to
manage them differently than if they
have crackles versus if they have
unilaterally absent breath sounds so
different lung sounds are going to help
us understand what the underlying
problem is and treat it accordingly
and then lastly we want to 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 want to check for C I want to
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 want to 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 want to recognize that
they are trying to physiologically
compensate for some underlying
derangement and you want to 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 going to 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 want to make sure we get two
large-bore IV catheters not one but two
and that's so important because we want
to 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 IVs infiltrates or falls
out we want to always have a backup so
that we're not facing interruptions or
obstacles in trying to treat our
critically ill patient we want to make
sure that we get a good look at the
monitor and differentiate those patients
who have non-scientists from those who
have sinus rhythms and again if they
have a non sinus rhythm we want to think
about treating it and lastly we want to
consider IV fluids now not every single
patient where the 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
not squeezing adequately to perfuse the
body that's a situation where fluid
isn't going to benefit you but in the
vast majority of cases filling up the
tank or optimizing intravascular volume
is going to be the first step in
stabilizing sea