TIPS for Emergencies

Dr. James Manos (MD)

April 17, 2020

                            TIPS for Emergencies

Image (public domain): This is the main patient area inside the Mobile Medical Unit in Belle Chasse, Louisiana. This configuration is an emergency department with minor surgery capability. Author: Robert Kaufmann. Date: October 25, 2005. Source: This image is from the FEMA Photo Library. Uploaded by the user Wikipedia Link: https://ro.wikipedia.org/wiki/Fi%C8%99ier:FEMA_-_18213_-_Photograph_by_Robert_Kaufmann_taken_on_10-25-2005_in_Louisiana.jpg

(You may print these pages)

Patient name: Age: LMP (last menstrual period) (women of childbearing age):

Weight (especially if child): Address: Cell phone:

HISTORY 

Subjective symptoms?/ First time?/ When did it start?/ Has it worsened?/ Other in the family or environment with the same symptoms? Hazards? Need for decontamination? / Count pain from 1 to 10 scale. // Any rash recently, e.g., measles encephalitis. 

Vitals

Pulse, respiratory rate (RR), blood pressure (BP), temperature (T), glucose (initially with finger stick), SaO2 (oxygen saturation)

High temperature: malignant hyperthermia (e.g., from the anesthetic halothane or the depolarizing muscle relaxant succinylcholine); people taking neuroleptics may develop malignant neuroleptic syndrome with hyperthermia; those who abuse illicit drugs, including cocaine and amphetamines such as Ecstasy, may also have hyperthermia)

(S)AMPLE

Signs  & Symptoms

Allergies (including drugs, bees, nuts, seafood, etc.)

Medications (anything, including non-prescribed drugs, herbs & lifestyle such as for sex (especially in case of myocardial infarction) or obesity (amphetamines?)

Past medical history (PMH)

Last meal (When? What? Any others with the same symptoms?)

Events and environment-related (e.g., to injury) (What happened? kinetics on traffic accident):

Α (Airway & cervical immobilization when needed)

1. Airway (Patent & Safe? Threatened? Obstructed?)

2. Do you suspect any cervical injury? (If yes, place a collar). A person riding a motorbike and involved in a traffic collision wearing a helmet also needs a collar after the removal of the helmet by skilled rescuers.  

3. Tracheal position (in the middle? Deviation? (tracheal shift towards the opposing side in tension pneumothorax)    

4. Jugular Veins Distension (JVD?) (Congestive Heart failure? Cardiac Tamponade? Tension Pneumothorax?) It may not appear in severe hypotension, e.g., from hypovolemia.

5. Kussmaul’s sign (increased JVP during inspiration) (cardiac tamponade? constrictive pericarditis? restrictive cardiomyopathy?) Beck’s triad in cardiac tamponade: hypotension, jugular vein, distention, distant, and muffled heart sounds.

B (Breathing)

1. Respiratory rate (RR)

2. Depth of breaths (shallow?)

3. Labored breathing (Accessory breathing muscles? Intercostal, sternal, and subcostal retraction or recession?)

4. Paradoxical breathing (‘seesaw,’ rocking, with the belly)? Nasal flaring? Head bobbing or grunting on babies?)

5. Bilateral equal chest expansion? (pneumothorax?)     

6. Decreased chest expansion (asthma/COPD?)

7. Lung auscultation: Bilateral equal breath sound (apices & bases)? (if not, consider pneumothorax)

8. Lung percussion (dullness? Stony dullness? //// Hyper-resonance? (consider pneumothorax) tympany? (consider tension pneumothorax)

9. Oxygen saturation (SaO2)

10. Place oxygen mask or nasal cannula (keep saturation > 90%)

Notes

1. Blood with chocolate, brown color may indicate methemoglobinemia. There is cyanosis with falsely normal arterial oxygen tension (PaO2), but the oxygen saturation may be low or overestimated. The key feature is the disparity between those 2. Pulse oximetry measurements with low levels of methemoglobinemia often result in falsely low values for oxygen saturation and are often falsely high in those with high-level methemoglobinemia. Cyanosis does not improve with the administration of Oxygen. 

2. In the case of carbon monoxide (CO) poisoning, carboxyhemoglobin causes pulse oximeters to register artificially high oxygen saturation (Spo2) values. Blood gas oxygen tension (PO2) measurements tend to be normal. A carboxyhemoglobin (HbCO) measurement is essential for determining exposure. Do not forget to check the ECG & cardiac markers.

There are special pulse oximeters that measure methemoglobin and carboxyhemoglobin (HbCO)

3. Cyanide poisoning may occur from smoke inhalation of burned wool, paper, cotton, silk, and plastics and consuming stone fruit seeds of Prunus species such as bitter almonds. Patients with cyanide poisoning present with respiratory distress and normal oxygen saturation, while the arterial blood gases ABGs may show anion gap metabolic acidosis. Cyanide toxicity is characterized by normal arterial oxygen tension and abnormally high venous oxygen tension, resulting in a decreased arteriovenous oxygen difference (less than 10%). 

C (Circulation)

1. Pulse Rate 

2. (first, the radial, if undetectable, try carotid – shock? Cardiac arrest?)

3. Pulse irregular? (atrial fibrillation (irregularly irregular) or flutter?)

4. Is pulse fast and thready? (hypovolemic shock?)

5. Pulsus paradoxus (decreasing pulse or systolic pressure fall > 10 mmHg during inspiration)? (cardiac tamponade? Constrictive pericarditis? Severe asthma? Tension pneumothorax? Pulmonary embolism?

6. Puslus alterans? (heart failure due to increased resistance to LV ejection, as occurs in hypertension, aortic stenosis, coronary atherosclerosis, and dilated cardiomyopathy)

7. Postural (orthostatic) hypotension (supine for 3 min, then erect for 1 min, increase on Heart Rate >_ 30 bpm, or decrease of Systolic BP> 20 mmHg or if Systolic BP < 90 mmHg)? If yes: Hemorrhage or severe dehydration? (it may be an early sign) Autonomic neuropathy? Medications?  

8. Dehydration? Initial signs/symptoms include thirst, dry tongue/buccal mucus membranes, decreased skin turgor, and reduced urine output. Severe dehydration signs include tachycardia, fast–thready pulse, little or no urine output, sunken eyes or fontanelles, orthostatic hypotension, hypotension, decreased capillary refill, mottled skin, and coma. The skin may be dry on the elderly, not necessarily indicating dehydration. The mouth may be dry (xerostomia) from Sjogren's syndrome or anticholinergic medications, including TCAs (tricyclic antidepressants).  

9. Difference in BP/ Radial pulse delay between upper extremities? (radio-radial delay). Causes include aortic dissection, subclavian artery stenosis, coarctation of the aorta, atherosclerosis (elderly), peripheral arterial disease (PAD), and other cardiovascular conditions.

Brachioradial delay? The right brachial and right radial pulse are simultaneously palpated. The radial pulse is felt after the brachial pulse in severe aortic stenosis. 

10. Delay in pulses between upper and lower extremities (radio-femoral delay). Causes include aortic dissection, coarctation of the aorta, thrombosis/embolism/ atherosclerosis of the aorta/ aortoarteritis, peripheral arterial disease (PAD), and other cardiovascular conditions.

Also, if the BP of the legs (lower calf) is higher than the BP of the arms, this may indicate aortic regurgitation. If it is lower (as in ankle-brachial index in PAD), the same causes as the pulse delay between the upper and lower extremities may be responsible (See (10)). 

11. Difference in femoral pulses between two lower extremities? (ruptured aneurysm? atherosclerosis?) Note: The presence or absence of femoral pulses cannot be relied on in establishing a diagnosis of a ruptured abdominal aneurysm since femoral pulses have been known to remain unchanged even though there was a rather massive extravasation of blood at the site of rupture. Pulsatile abdominal mass (abdominal aneurysm), groin mass (femoral aneurysm?), or popliteal fossa (popliteal artery aneurysm). 

13. Flank ecchymosis (Grey Turner sign)? (represents retroperitoneal hemorrhage)(Acute pancreatitis? Retroperitoneal hemorrhage? Aortic rupture from ruptured abdominal aortic aneurysm? Blunt abdominal trauma? Ruptured ectopic pregnancy? Spontaneous bleeding from coagulopathy?) Cullen's sign (hemorrhagic discoloration of the umbilicus) (Acute pancreatitis? Hemorrhage from blunt abdominal trauma? Aortic aneurysm rupture? Ruptured ectopic pregnancy?)

14. Heart auscultation: heart sounds (Audible S3/ S4? Loud S1/S2? Soft S1/S2? Normal splitting of S2? Widely or Reversed Splitting of S1?) Mid-systolic click? Ejection click? S3?S4? (gallop).

15. Murmur (diastolic? systolic? Continuous? Expands at the axilla or carotids?)? Thrill? Carotid bruits?

16. Apical impulse (displaced? Apical thrust? Double systolic? Sustained lift? Dyskinetic?)

17. PR (per rectum) examination in case of suspected gastrointestinal hemorrhage.  

18. Connect the patient on a monitor: 12 lead ECG (in the case of a cardiac arrest, you attach pads/paddles of the defib – ‘quick look!’)

19. IV access, take blood for Labs (also blood pregnancy test if indicated; blood type & crossmatch if hypovolemia)

20. Urinalysis (stick) (increased urine protein in pregnancy or early puerperium may indicate pre-eclampsia)                                  

                   

21. Glucose finger stick (hypoglycemia may mimic stroke)

22. Is Capillary refill time (index) prolonged? (> 3 min) (normal range<_3) (prolonged: hypovolemic shock?)

23. Color and temperature of the skin (cold & clammy? (hypovolemic shock?) /// Peripheral cyanosis? Central cyanosis (mouth, tongue)?)

24. Signs of cardiac failure (ankles edema, basal rales at lungs, jugular vein distension, pulsus alterans, and on children liver enlargement)?

25. ΑΒGs (arterial blood gases)

D (Disability) 

AVPU (Alert/ responds to vocal stimuli/ to pain/ unresponsive) or GCS.

Also, pupils' size & reaction. Opioids and organophosphates will cause small pupils (pinpoint on opioids; pontine hemorrhage also causes pinpoint pupils).

LOC (level of consciousness): Confusion? Stupor? Comma? Do not forget the Babinski reflex (plantar) in comatose patients to exclude, for example, a stroke. 

Abnormal posture of flexion or extension?

Note: blood ammonia levels may be requested to investigate unexplained neurological dysfunction (including inherited errors of metabolism and hepatic encephalopathy).

GCS (Glasgow coma scale)

Eye Opening (E4). 

Response to pain is checked by pressing the patient’s nail bed with a pen. If there is no response, try supraorbital pressure and sternal pressure. Be careful about eye drop use, eye operation, or fake eye!

4 0 – 1-year old: spontaneously; > 1-year-old: spontaneously

3 child: to sound; adult: to verbal command (in response to voice but not 

 necessarily to ‘open your eyes’)

2 all ages: to pain

1 all ages: no response (does not open eyes)

NT: not tested, e.g., severe trauma to eyes, enucleation. 

Best Verbal Response (V5)

5 0 – 2-year-old: coos and babbles; 2 – 17-year-old: orientated and appropriate; adults: oriented to time, person, and place, converses normally

4 children: irritable cries; 2 – 17-year-old: confused; adult: confused and disoriented but able to answer questions

3 <2-year-old:  cries in response to pain; 2 – 17-year-old: incomprehensible words; adult: inappropriate words

2 <2-year-old: moans in response to pain; 2-year-old - 17-year-old: incomprehensible sounds

1 all ages: no response (makes no sounds)

NT: not tested, e.g., intubation, non-oral language disability, linguistic barrier

Best Motor Response (M6).  

The motor response may be, e.g., ‘raise your hand.’ It is the better response of any limb. Be careful of paralysis and grasp reflex.

6 0 – 2-year-old: moves spontaneously and purposefully; >2-year-old: obeys commands

5 <2-year-old: withdraws to touch; >2-year old: moves to localize pain 

4 all ages: flexion/withdrawal from painful stimuli

3 all ages: decorticate posture (abnormal flexion)

2 all ages: decerebrate posture (abnormal extension) 

1 all ages: no response (makes no movements ) 

NT: not tested, e.g., paralysis/hemiparesis (acquired causes such as post-stroke, post-neurological injury; congenital/innate such as cerebral palsy)

Score: min 3, max 15. If GCS<_8 the patient needs intubation (RSI rapid sequence intubation if GCS > 3).  In the case of head trauma, GCS <_8 indicates a severe injury, GCS 9 –12 moderate injury, GCS 13–15 minor injuries. 

Tracheal intubation and severe facial/eye swelling or damage make testing the verbal and eye responses impossible. In these cases, the score is given as 1 with a modifier attached (e.g., "E1c", where "c" = closed, or "V1t" where t = tube). Often, the 1 is left out, so the scale reads Ec or Vt. A composite might be "GCS 5tc". This would mean, for example, eyes closed because of swelling = 1, intubated = 1, leaving a motor score of 3 for "abnormal flexion."

Stroke assessment

Confusion/ decreased LOC (Level of consciousness)? Limb weakness/ paralysis? Slurring speech? 

Cincinnati Prehospital Stroke Scale

1 of the following suggests the possibility of stroke:

a) Facial droop (‘smile’)

b) Arm drift (‘raise both arms with your eyes CLOSED’)

c) Speech (slurred, mute, inappropriate words, dysarthria).

3. Symptoms NOT improving spontaneously (differential diagnosis with TIA transit ischemic attack).

ABCDs, glucose finger stick, check electrolytes, and BP. Do not give D5W (5% dextrose)

E (Expose/ Environment) (+call Expert!)  

Remove the patients’ clothes. Check the skin for injury, rash, petechiae, hives, etc. In the case of trauma, skilled rescuers should Log – Roll (with the spine aligned) the patient and check the back. Then, with blankets, prevent hypothermia.

Other Signs

Dark or tea-colored urine with positive Hb urine stick? (rhabdomyolysis) (increasing amounts of blood by urinalysis progressively raises the probability of myoglobinuria, especially in the absence of hematuria)     

Delay of expected LMP (Last Menstrual Period): Ectopic? Molar pregnancy?   

Fetor/ odor, e.g., hepatic (like sweet musty); Ketotic in diabetic ketoacidosis (like fruit); cyanide poisoning (like almond), ammonia in chronic kidney failure/ uremic (like urine or fishy), hydrogen sulfide poisoning (like a rotten egg), phosgene poisoning (like mown hay). 

Kussmaul respiration (Diabetic ketoacidosis?)

Cheyne Stokes respiration? 

Babinski (upgoing plantar)? (Stroke?)  

Ocular movements, convergence & adaptation (stroke?) 

Lateralizing signs? (stroke?))

Meningeal (meningitis) signs?

Nystagmus/ vertigo? (Ear? Central nervous system?)

Asterixis (flapping)? (liver failure?)

PR (per rectum) examination (rectum, prostate, sphincter tone)

Treatment - Medications 

Date, time, and place of examination

Doctors’ name and signature

Reference:

BIBLIOGRAPHY

1) Longmore M., Wilkinson I.B, Davidson E.H., Foulkes A., Mafi A.R., Oxford Handbook of Clinical Medicine, Oxford Medical Publications, 8th edition, 2010.

2) Stone C.K., Humphries R.L., Current Diagnosis and Treatment in Emergency Medicine, McGraw Hill - LANGE, 6th edition, 2008

3) Ramrakha P., Moore K., Oxford Handbook of Acute Medicine, Oxford Medical Publications, 2nd edition, published 2004, reprinted 2005.

4) ALS (Advanced Life Support), European Resuscitation Council, 5th edition, The Image Factory, Belgium,2006.

5) EPLS (European Pediatric Life Support), European Resuscitation Council, 3rd edition, The Image Factory, Belgium, 2006.

6) Llewelyn H., Aun Ang H., Lewis K., Al–Abdulla A., Oxford Handbook of Clinical Diagnosis, Oxford Medical Publications, 2006.

7) Thomas J., Monaghan T., Oxford Handbook of Clinical Examination and Practical Skills, Oxford Medical Publications, 2008.

8) Richards D., Aronson J., Oxford Handbook of Practical Drug Therapy, Oxford Medical Publications, 2008.

9) ATLS (Advanced Trauma Life Support), American College of Surgeons – Committee on Trauma, Students Course Manual, First Impression, 7th edition, 2002.

10) PHTLS (Prehospital Trauma Life Support, basic & advanced), Prehospital Trauma Life Support Committee of the National Association of Emergency Medical Technicians in association with The Committee of Trauma of the American College of Surgeons, 5th edition (revised), Mosby, inc, 2003.

11) ALSO (Advanced Life Support in Obstetrics), American Academy of Family

Physicians, 4th edition (revised), 2006.

12) Kasper D.L., Braunwald E., Fauci A.S., Hauser S.L., Longo D.L., Jameson J.L., Harrison’s Manual of Medicine, McGraw–Hill, 16th edition, 2005.

13) Simon C., Everitt H., Kendrick T., Oxford Handbook of General Practice, Oxford Medical Publications, 2nd edition, 2005.

14) Wyatt J.P., Illingworth R.N., Graham C.A., Clancy M.J., Robertson C.E., Oxford Handbook of Emergency Medicine, Oxford Medical Publications, 3rd edition, 2006

15) Collier J., Longmore M., Brinsden M., Oxford Handbook of Clinical Specialties, Oxford Medical Publications, 7th edition, 2006.

16) ACLS (Advanced Cardiac Life Support), American College of Emergency Physicians, Study Guide, 2nd edition, Jones and Bartlett Publishers, 2007.

Links  

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3058018/

https://www.sciencedirect.com/topics/neuroscience/cyanide-poisoning

https://www.archivesofpathology.org/doi/pdf/10.5858/arpa.2018-0475-OA

https://www.medscape.com/answers/204178-70238/what-is-the-role-of-pulse-oximetry-in-the-workup-of-methemoglobinemia

https://jamanetwork.com/journals/jamapediatrics/article-abstract/514678

https://emcrit.org/ibcc/methemoglobinemia/

https://www.sciencedirect.com/topics/veterinary-science-and-veterinary-medicine/capillary-refill

https://journals.lww.com/anesthesia-analgesia/fulltext/2011/07000/capillary_refill_time___is_it_still_a_useful.21.aspx

https://www.bjanaesthesia.org.uk/article/S0007-0912(17)48117-7/pdf

https://www.sciencedirect.com/topics/neuroscience/carboxyhemoglobin

https://www.uptodate.com/contents/carbon-monoxide-poisoning

https://www.ncbi.nlm.nih.gov/books/NBK513297/

https://www.sciencedirect.com/topics/medicine-and-dentistry/hypovolemic-shock

https://care.diabetesjournals.org/content/37/11/3124

https://www.ahajournals.org/doi/full/10.1161/JAHA.119.011991

https://emedicine.medscape.com/article/1175139-clinical

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5615427/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1031608/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3716484/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1127586/

https://www.annalsthoracicsurgery.org/article/S0003-4975(10)66558-7/pdf

https://fpnotebook.com/cv/valve/artcstns.htm