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ER6 Emergency Medicine
Patient Assessment/Management Toronto Notes 2019 PHYSICAL EXAM
Head and Neck
• palpationoffacialbones,scalp
Chest
• inspectformidlinetracheaandflailsegment:≥2ribfracturesin≥2places;ifpresentlookforassociated hemothorax, pneumothorax, and contusions
• auscultatelungfields
• palpateforsubcutaneousemphysema
Abdomen
• assessforperitonitis,abdominaldistention,andevidenceofintra-abdominalbleeding • DREforGIbleed,highridingprostate,andanaltone
Musculoskeletal
• examineallextremitiesforswelling,deformity,contusions,tenderness,ROM
• checkforpulses(usingDopplerprobe)andsensationinallinjuredlimbs
• log roll and palpate thoracic and lumbar spines
• palpateiliaccrestsandpubicsymphysisandassesspelvicstability(lateral,AP,vertical)
Neurological
• GCS
• fullcranialnerveexam
• alterationsofrateandrhythmofbreathingaresignsofstructuralormetabolicabnormalitieswith
progressive deterioration in breathing indicating a failing CNS
• assessspinalcordintegrity
• consciouspatient:assessdistalsensationandmotorfunction
• unconsciouspatient:responsetopainfulornoxiousstimulusappliedtoextremities
INITIAL IMAGING
• non-contrastCThead/face/C-spine(ruleoutfracturesandbleeds) • chestx-ray
• FAST(seeFigure2)orCTabdomen/pelvis(ifstable)
• pelvisx-ray
Ethical Considerations
Consent to Treatment: Adults
• seeEthical,Legal,andOrganizationalMedicine,ELOM7
• EmergencyRule:consentisnotneededwhenapatientisatimminentriskfromaseriousinjuryAND
obtaining consent is either: a) not possible, OR b) would increase risk to the patient ■ assumes that most people would want to be saved in an emergency
• anycapableandinformedpatientcanrefusetreatmentorpartoftreatment,evenifitislife-saving • exceptionstotheEmergencyRule–treatmentcannotbeinitiatedif
■ a competent patient has previously refused the same or similar treatment and there is no evidence to suggest the patient’s wishes have changed
■ an advanced directive is available (e.g. do not resuscitate order)
■ NOTE: refusal of help in a suicide situation is NOT an exception; care must be given • if in doubt, initiate treatment
• carecanbewithdrawnifnecessaryatalatertimeorifwishesareclarifiedbyfamily
Consent to Treatment: Children
• treatimmediatelyifpatientisatimminentrisk
• parents/guardians have the right to make treatment decisions
• ifparentsrefusetreatmentthatislife-savingorwillpotentiallyalterthechild’squalityoflife,CASmust
be contacted – consent of CAS is needed to treat
Other Issues of Consent
• needconsentforHIVtesting,aswellasforadministrationofbloodproducts
• however,ifdelayinsubstituteconsentforbloodtransfusionsputspatientatrisk,transfusionscanbe
given
Duty to Report
• lawmayvarydependingonprovinceand/orstate
• examples:gunshotwounds,suspectedchildabuse,variouscommunicablediseases,medical
unsuitability to drive, risk of substantial harm to others
Signs of Increased ICP
• Deteriorating LOC (hallmark)
• Deteriorating respiratory pattern
• Cushing reflex (high BP, low heart rate,
irregular respirations)
• Lateralizing CNS signs (e.g. cranial nerve
palsies, hemiparesis)
• Seizures
• Papilledema (occurs late)
• N/V and headache
Non-contrast head CT is the best imaging modality for intracranial injury
Jehovah’s Witnesses
• Capable adults have the right to refuse medical treatment
• May refuse whole blood, pRBCs, platelets, and plasma even if life-saving
• Should be questioned directly about the use of albumin, immunoglobulins, hemophilic preparations
• Do not allow autologous transfusion unless there is uninterrupted extra corporeal circulation
• Usually ask for the highest possible quality of care without the use of the above interventions (e.g. crystalloids for volume expansion, attempts at bloodless surgery)
• Patient will generally sign hospital forms releasing medical staff from liability
• Most legal cases involve children of
Jehovah’s Witnesses; if life-saving treatment is refused, contact CAS