Severe trauma (ATLS) and cardiac patients (ACLS) make up only a part of the total number of patients seen in the emergency setting. To deal with a broad range of medical emergencies eg, acute asthma, severe pneumonia, pulmonary embolism, pulmonary edema, exacerbation of COPD, poisoning, status epileptics etc, we will now outline an approach to the management of patients presenting with these problems. There is obviously a certain amount of overlap with the ACLS and ATLS approaches, but it is however useful to present an approach to these conditions separately as they constitute a large proportion of emergencies seen.
INITIAL STABILIZATION
- ASSESSMENT OF VITAL FUNCTIONS AND IMMEDIATE TREATMENT OF IDENTIFIED LIFE THREATENING ABNORMALITIES
1. POSITION PATIENT APPROPRIATELY
a) The unconscious patient
To avoid obstruction of the airway, position the patient head down and in the left lateral position, with neck flexed and head extended (if trauma and cervical spine injury is suspected, do not move the neck). This prevents the tongue from falling back over the airway. Also, if the patient vomits, it is more likely to run out of the mouth rather than down the airway.
b) The dyspeptic patient
The patient who is dyspnoeic will often prefer to sit upright. There are good physiological reasons for this. It enables optimal use of accessory muscles of respiration and in the case of pulmonary o edema, helps reduce shunting. Managing these patients in the upright position will not only reduce asphyxia, but also get maximal co-operation.
c) The child with partial upper airway obstruction
Unless the child is in extremist, the best place is sitting up in the parent's lap. The sitting position allows the child to hold the head and neck in a way that maintains potency of the airway. Being seated on the lap has a calming effect on children in an environment, which is quite frightening to them. This may decrease the risk of converting a partial airway obstruction into a complete one.
d) The shocked patient
The supine position is best for patients in shock. It allows for the most efficient use of the cardiovascular compensatory mechanism and hence, the best per fusion of the vital organs. The use of Brandenburg (feet elevated above the head) is controversial and has not been shown to make any difference to patient outcome or improve physiological parameters.
e) The head injured patient
Unless shock or spinal injury is present, patients should be positioned with head elevated at 30 degrees to the horizontal. This may reduce intracranial pressure.
f) The patient with facial trauma or partial upper airway obstruction
from any cause If the patient is conscious and does not have a significant cervical spine injury,
encourage self posturing to maintain airway patency. In the setting of facial trauma this helps to prevent any facial fractures from falling backwards and occluding the airway, and will also stop blood from running down the airway.
g) The pregnant patient
In the third trimester of pregnancy care has to be taken if the patient is lying flat to prevent supine hypo tension from vane cavil compression. This will require a wedge under the right flank or positioning of the patient in the left lateral position.
2. AIRWAY
Keep patent. This may require a combination of standard airway opening man oeuvres or more complex man oeuvres. Protect cervical spine with a hard collar or in line immobilization if there is a suspicion of trauma.
3. BREATHING
Measure the respiratory rate. If inadequate, assist ventilation with a bag valve bag (Am bu Bag) attached to oxygen.
Measure SaO2. If < 95% and not requiring assisted ventilation, administer oxygen via an appropriate face mask at a rate according to the clinical circumstance.
4. CIRCULATION
- If in cardiac arrest, commence CPR, otherwise:
- Measure pulse rate, blood pressure and capillary refill
- Attach to a cardiac monitor and assess the rhythm. Correct any life threatening rhythm disturbances.
- Insert an IV cannula
- Take blood from the annular for appropriate blood tests
- If in shock, give fluids and heliotropes as appropriate
5. DISABILITY
Record a Glasgow Coma Scale (GCS) and pupil response. If GCS 8 or less, consider incubation to protect the airway.
6. MEASURE
Temperature and finger prick sugar
7. MONITOR
ECG, SaO2, Blood pressure
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