emergency thinking
reuben j. strayer mount sinai school of medicine
2
objectives
bottom up approach our responsibilities top down approach resuscitation strayer system caveat emptor be aware of your system
3
the bottom-up approach what does this patient have?
treatment final diagnosis ancillary testing differential diagnosis physical exam
dyspnea and reuben as a junior resident
history
4
Airway obstruction ALS Anaphylaxis Anemia Ascites Aspiration Asthma Carbon monoxide poisoning Cardiac tamponade Cardiomyopathy Congenital heart disease COPD Cor pulmonale CVA Diaphragmatic rupture DKA Electrolyte abnormalities Epiglottitis Fever Flail chest Guillain-Barré syndrome Hemothorax Hyperventilation syndrome Intracranial insult Metabolic acidosis
Multiple sclerosis Myocardial infarction Neoplasm Noncardiogenic edema Obesity Organophosphate poisoning Panic attack Pericarditis Pleural effusion Pneumonia Polymyositis Porphyria Pregnancy Pulmonary edema Pulmonary embolus Renal failure Rib fractures Sepsis Somatization disorder Spontaneous pneumothorax Tension pneumothorax Thyroid disease Tick paralysis Toxic ingestion Valvular heart disease
5
treatment final diagnosis
ancillary testing
physical exam history acute dyspnea
Airway obstruction Multiple sclerosis ALS Myocardial infarction Anaphylaxis Neoplasm Anemia Noncardiogenic edema Ascites Obesity Aspiration Organophosphate poisoning Asthma Panic attack Carbon monoxide poisoning Pericarditis Cardiac tamponade Pleural effusion Cardiomyopathy Pneumonia Congenital heart disease Polymyositis COPD Porphyria Cor pulmonale Pregnancy CVA Pulmonary edema Diaphragmatic rupture Pulmonary embolus DKA Renal failure Electrolyte abnormalities Rib fractures Epiglottitis Sepsis Fever Somatization disorder Flail chest Spontaneous pneumothorax Guillain-Barré syndrome Tension pneumothorax Hemothorax Thyroid disease Hyperventilation syndrome Tick paralysis Intracranial insult Toxic ingestion Metabolic acidosis Valvular heart disease
EPs cannot think this way experienced EPs don’t think this way, but may not realize they don’t think this way
6
the top-down approach what does this patient need? acute dyspnea IV, O2, monitor chest decompression?
chest trauma breath sounds neck veins
intubate? epinephrine? nebulized albuterol? nitroglycerine? CXR, ECG, sono NIV? magnesium? steroids? antibiotics? anticoagulation/ reperfusion? pericardial decompression? inotropes? H&P, further testing, specific therapy
responsibilities of the emergency physician
7
patient safety
symptom relief
customer service
resource stewardship
responsibilities of the emergency physician
8
patient safety
symptom relief
customer service
resource stewardship
the most expensive piece of medical equipment is the doctor’s pen
responsibilities of the emergency physician
9
patient safety
symptom relief
customer service
resource stewardship
best practice ≠ customer service
I don’t know for certain what’s causing your pain but
this is going to take longer than you can possibly imagine
do you have any particular concern? what do you think is going on?
a few minutes
asystole
laceration chronically ill
is there anything I can do to make you more comfortable while you wait?
responsibilities of the emergency physician
10
patient safety
symptom relief
customer service
morphine acetaminophen prochlorperazine metoclopramide diphenhydramine ondansetron normal saline valium
haldol ativan succinylcholine
don’t forget do you need more medication for pain?
resource stewardship
responsibilities of the emergency physician
11
patient safety
symptom relief
resuscitation
customer service
resource stewardship
identifying dangerous conditions [pause]
costochondritis what the patient has vs. what the patient needs: thinking from the top down
12
dangerous conditions wheel
13
eye pain / visual loss
14
back pain
vs bottom up headache
15
headache
16 Fever? Meningismus?
headache
Thrombophilia? Altitude?
Elderly? Jaw, visual, scalp symptoms?
Visual disturbance? Abnormal eye exam?
Anyone else at home affected?
Neck pain? Horners? Neck manipulation?
Hypertension?
Cancer history?
Maximal intensity at time of onset? Trauma? Bleeding diathesis? Level of consciousness?
be directed not exhaustive the next step
17
tests procedures
interventions wheel
medications
18
arthrocentesis xray immobilization referral analgesia crutches
knee pain
red, hot joint? exquisitely painful ROM? risk factors?
infectious arthritis
trauma? unstable knee?
knee dislocation
trauma? ottawa positive?
fracture
abnormal patella location?
patellar dislocation
weakness or inability to extend knee?
quadriceps tendon rupture
extra-articular findings? risk factors?
DVT
rubor, calor, dolor, etc. outside of joint?
soft tissue infection
19
20
acute dyspnea
Airway obstruction Multiple sclerosis ALS Myocardial infarction Anaphylaxis Neoplasm Anemia Noncardiogenic edema Ascites Obesity Aspiration Organophosphate poisoning Asthma Panic attack Carbon monoxide poisoning Pericarditis Cardiac tamponade Pleural effusion Cardiomyopathy Pneumonia Congenital heart disease Polymyositis COPD Porphyria Cor pulmonale Pregnancy CVA Pulmonary edema Diaphragmatic rupture Pulmonary embolus DKA Renal failure Electrolyte abnormalities Rib fractures Epiglottitis Sepsis Fever Somatization disorder Flail chest Spontaneous pneumothorax Guillain-Barré syndrome Tension pneumothorax Hemothorax Thyroid disease Hyperventilation syndrome Tick paralysis Intracranial insult Toxic ingestion Metabolic acidosis Valvular heart disease
acute dyspnea
IV, O2, monitor
chest decompression?
intubate? epinephrine? nebulized albuterol? nitroglycerine? CXR, ECG, sono NIV? magnesium? steroids? antibiotics? anticoagulation/reperfusion? pericardial decompression? inotropes?
H&P, further testing, specific therapy
resuscitation
21
take your own pulse
Danger C all for help Defibrillate C spine A irway B reathing C irculation Disability E xposure U ltrasound
safe to approach patient? PPE? decontaminate? nursing & technicians, your attending, a colleague, a consultant, respiratory check a rhythm with paddles? don’t forget repositioning? suction? FB removal? ETT/LMA?
equipment meds
O2, respiratory effort, breath sounds, saturation, CXR, BVM/NIV? albuterol? needle? pulses, monitor, BP, skin, access, ECG, fluids glucose, pupils, mentation/GCS, focal neuro deficits/strength at all four disrobe and visualize every inch of skin, consider rectal hemeoccult/tone/temp pericardial effusion, free abdominal fluid, AAA, urinary retention, line?
strayer system
22
resuscitate? vitals AND / AMS concern for deterioration threat to self/others
identify dangerous conditions nursing notes prior visits & medical records EMS run sheet
what is the patient waiting on? results? change in status? customer service? document
run your board orders before documentation
PMH medications, especially recent changes/compliance allergies social: functional status, living situation, bad habits HPI: USOH until ____, why today?
move to resus
manage interruptions multi-tasking is a myth leave the obvious for last
dangerous conditions
complains of DCDC ABCDE U
vs.
ROS tailored to dangerous conditions prior episodes / prior workups
endorses
wellness vitals including room air pulse ox mentation head to toe including gait & skin exam
expand your testing when history/physical limited wastebasket diagnoses
interventions
plan for negatives
follow key cases
23
resource stewardship
customer service
be wary the cost of the doctor’s pen
identify why the patient is really here, right now manage expectations: this is going to take longer than you can possibly imagine.
resuscitate vitals AND / AMS concern for deterioration threat to self/others
D anger C all for help D efibrillate C spine A irway B reathing C irculation D isability E xposure U ltrasound
identify dangerous conditions nursing notes prior visits & medical records EMS run sheet PMH medications, especially recent changes/compliance allergies social: functional status, living situation, bad habits HPI: USOH until, why today? ROS tailored to dangerous conditions prior episodes / prior workups dangerous conditions wellness vitals including room air pulse ox mentation head to toe including gait & skin exam
interventions
plan for negatives
symptom relief analgesic antiemetic antipyretic antihistamine
anticholinergic anxiolytic anti-inflammatory intravenous fluids
do you need more medicine for pain?
run your board orders before documentation manage interruptions leave the obvious for last complains of vs. endorses expand your testing when history/physical limited wastebasket diagnoses follow key cases
24
[email protected]
