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ER4 Emergency Medicine
Patient Assessment/Management Toronto Notes 2019
Management of Hemorrhagic Shock
• clearairwayandbreathingeitherfirstorsimultaneously
• applydirectpressureonexternalwoundswhileelevatingextremities.Donotremoveimpaledobjectsin
the emergency room setting as they may tamponade bleeds
• start TWO LARGE BORE (14-16G) IVs in the brachial/cephalic vein of each arm
• run1-2LbolusofIVNormalSaline/Ringer’sLactate(warmed,ifpossible)
• ifcontinualbleedingornoresponsetocrystalloids,considerpRBCtransfusion,ideallycrossmatched.
If crossmatched blood is unavailable, consider O- for women of childbearing age and O+ for men. Use
FFP, platelets or tranexamic acid in early bleeding
• considercommonsitesofinternalbleeding(abdomen,chest,pelvis,longbones)wheresurgical
intervention may be necessary
D . DISABILITY
• assessLOCusingGCS • pupils
■ assess equality, size, symmetry, reactivity to light
◆ inequality/sluggish suggests local eye problem or lateralizing CNS lesion
◆ relative afferent pupillary defect (swinging light test) – optic nerve damage
■ extraocular movements and nystagmus
■ fundoscopy (papilledema, hemorrhages)
■ reactive pupils + decreased LOC: metabolic or structural cause
■ non-reactive pupils + decreased LOC: structural cause (especially if asymmetric)
Glasgow Coma Scale
• foruseintraumapatientswithdecreasedLOC;goodindicatorofseverityofinjuryandneurosurgical prognosis
• mostusefulifrepeated;changeinGCSwithtimeismorerelevantthantheabsolutenumber • less meaningful for metabolic coma
• patientwithdeterioratingGCSneedsimmediateattention
• prognosisbasedonbestpost-resuscitationGCS
• reportedasa3partscore:Eyes+Verbal+Motor=Total
• ifpatientintubated,GCSscorereportedoutof10+T(T=tubed,i.e.noverbalcomponent)
3:1 Rule
Since only 30% of infused isotonic crystalloids remains in intravascular space, you must give 3x estimated blood loss
Common Sites of Bleeding
• External (e.g. scalp)
• Chest
• Abdomen (peritoneum, retroperitoneum) • Pelvis
• Long bones
Fluid Resuscitation
• Give bolus until HR decreases, urine output increases, and patient stabilizes
• Maintenance: 4:2:1 rule
• 0-10 kg: 4 cc/kg/h
• 10-20 kg: 2 cc/kg/h
• Remaining weight: 1 cc/kg/h
• Replace ongoing losses and deficits
(assume 10% of body weight)
Table 3. Glasgow Coma Scale
Eyes Open
Spontaneously 4 To voice 3 To pain 2 No response 1
Best Verbal Response
Answers questions appropriately 5 Confused, disoriented 4 Inappropriate words 3 Incomprehensible sounds 2 No verbal response 1
Best Motor Response
Obeys commands 6 Localizes to pain 5 Withdraws from pain 4 Decorticate (flexion) 3 Decerebrate (extension) 2 No response 1
Unilateral, Dilated, Non-Reactive Pupil, Think
• Focal mass lesion
• Epidural hematoma
• Subdural hematoma
Contraindications to Foley Insertion
• Blood at urethral meatus
• Scrotal hematoma
• High-riding prostate on DRE
NG Tube Contraindications
• Significant mid-face trauma • Basal skull fracture
13-15 = mild injury, 9-12 = moderate injury, ≤8 = severe injury See Table 36, ER57 for Modified GCS for infants and children
E . EXPOSURE/ENVIRONMENT
• exposepatientcompletelyandassessentirebodyforinjury;logrolltoexamineback • DRE
• keeppatientwarmwithablanket±radiantheaters;avoidhypothermia
• warmIVfluids/blood
• keepproviderssafe(contamination,combativepatient)
2. Resuscitation
• doneconcurrentlywithprimarysurvey
• attend to ABCs
• manage life-threatening problems as they are identified
• vitalsignsq5-15min
• ECG, BP, and O2 monitors
• FoleycatheterandNGtubeifindicated
• testsandinvestigations:CBC,electrolytes,BUN,Cr,glucose,amylase,INR/PTT,β-hCG,toxicology
screen, cross and type