emergency thinking reuben j. strayer mount sinai school of medicine - PowerPoint PPT Presentation

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 treatment what does this patient have? final diagnosis ancillary testing differential diagnosis physical exam dyspnea and reuben as a junior resident history

4 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

5 treatment Airway obstruction Multiple sclerosis ALS Myocardial infarction Anaphylaxis Neoplasm Anemia Noncardiogenic edema final diagnosis Ascites Obesity Aspiration Organophosphate poisoning Asthma Panic attack Carbon monoxide poisoning Pericarditis Cardiac tamponade Pleural effusion Cardiomyopathy Pneumonia Congenital heart disease Polymyositis COPD Porphyria ancillary testing Cor pulmonale Pregnancy CVA Pulmonary edema Diaphragmatic rupture Pulmonary embolus DKA Renal failure Electrolyte abnormalities Rib fractures Epiglottitis Sepsis Fever Somatization disorder physical exam Flail chest Spontaneous pneumothorax Guillain-Barré syndrome Tension pneumothorax Hemothorax Thyroid disease Hyperventilation syndrome Tick paralysis Intracranial insult Toxic ingestion history Metabolic acidosis Valvular heart disease EPs cannot think this way acute dyspnea 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 trauma chest decompression? 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 this is going to take longer than you I don’t know for certain what’s causing can possibly imagine your pain but do you have any particular concern? a few minutes what do you think is going on? is there anything I can do to make you asystole laceration chronically ill more comfortable while you wait?

responsibilities of the emergency physician 10 patient safety symptom relief customer service resource stewardship morphine acetaminophen prochlorperazine haldol metoclopramide ativan diphenhydramine succinylcholine ondansetron normal saline valium don’t forget do you need more medication for pain?

responsibilities of the emergency physician 11 patient safety symptom relief customer service resource stewardship identifying dangerous resuscitation 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

headache 16 Thrombophilia? Fever? Meningismus? 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? be directed not exhaustive Trauma? Bleeding diathesis? Level of the next step consciousness?

17 tests procedures interventions wheel medications

knee pain 18 red, hot joint? infectious arthritis exquisitely painful ROM? risk factors? trauma? knee dislocation unstable knee? arthrocentesis trauma? fracture xray ottawa positive? immobilization patellar dislocation abnormal patella location? referral analgesia weakness or inability quadriceps tendon rupture crutches to extend knee? extra-articular findings? DVT risk factors? rubor, calor, dolor, etc. soft tissue infection outside of joint?

19

20 acute dyspnea acute dyspnea IV, O2, monitor Airway obstruction Multiple sclerosis ALS Myocardial infarction Anaphylaxis Neoplasm Anemia Noncardiogenic edema chest decompression? Ascites Obesity Aspiration Organophosphate poisoning Asthma Panic attack Carbon monoxide poisoning Pericarditis intubate? Cardiac tamponade Pleural effusion Cardiomyopathy Pneumonia Congenital heart disease Polymyositis epinephrine? nebulized COPD Porphyria albuterol? nitroglycerine? Cor pulmonale Pregnancy CVA Pulmonary edema Diaphragmatic rupture Pulmonary embolus CXR, ECG, sono DKA Renal failure Electrolyte abnormalities Rib fractures Epiglottitis Sepsis NIV? magnesium? steroids? antibiotics? Fever Somatization disorder anticoagulation/reperfusion? pericardial Flail chest Spontaneous pneumothorax decompression? inotropes? Guillain-Barré syndrome Tension pneumothorax Hemothorax Thyroid disease Hyperventilation syndrome Tick paralysis Intracranial insult Toxic ingestion H&P , further testing, specific therapy Metabolic acidosis Valvular heart disease

resuscitation 21 take your own pulse D anger safe to approach patient? PPE? decontaminate? C all for help nursing & technicians, your attending, a colleague, a consultant, respiratory D efibrillate check a rhythm with paddles? C spine don’t forget A irway equipment repositioning? suction? FB removal? ETT/LMA? meds B reathing O 2 , respiratory effort, breath sounds, saturation, CXR, BVM/NIV? albuterol? needle? C irculation pulses, monitor, BP , skin, access, ECG, fluids D isability glucose, pupils, mentation/GCS, focal neuro deficits/strength at all four E xposure disrobe and visualize every inch of skin, consider rectal hemeoccult/tone/temp U ltrasound pericardial effusion, free abdominal fluid, AAA, urinary retention, line?

strayer system 22 what is the patient waiting on? results? change in status? customer service? identify dangerous conditions resuscitate? document nursing notes run your board prior visits & medical records EMS run sheet vitals AND / AMS orders before documentation concern for deterioration PMH threat to self/others medications, especially recent changes/compliance manage interruptions allergies social: functional status, living situation, bad habits multi-tasking is a myth HPI: USOH until ____, why today? move to resus leave the obvious for last dangerous conditions complains of vs. ROS tailored to dangerous conditions endorses DCDC ABCDE U prior episodes / prior workups wellness vitals including room air pulse ox expand your testing when mentation history/physical limited head to toe including gait & skin exam wastebasket diagnoses interventions follow key cases plan for negatives

resource stewardship customer service symptom relief 23 be wary the cost of the doctor’s pen identify why the patient is really analgesic anticholinergic here, right now antiemetic anxiolytic manage expectations: this is going to take antipyretic anti-inflammatory longer than you can possibly imagine. antihistamine intravenous fluids do you need more medicine for pain? identify dangerous resuscitate conditions vitals run your board AND / AMS nursing notes concern for deterioration prior visits & medical records threat to self/others EMS run sheet orders before documentation PMH D anger medications, especially recent changes/compliance manage interruptions C all for help allergies social: functional status, living situation, bad habits D efibrillate HPI: USOH until, why today? leave the obvious for last C spine ROS tailored to dangerous conditions prior episodes / prior workups A irway complains of B reathing vs. dangerous conditions endorses C irculation D isability wellness expand your testing when vitals including room air pulse ox E xposure history/physical limited mentation U ltrasound head to toe including gait & skin exam wastebasket diagnoses interventions follow key cases plan for negatives

24 reuben.strayer@mssm.edu