CIECER（Critical Illness for Evaluation and Care in Emergency Room）

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• #1.

  (Critical Illness for Evaluation and Care in Emergency Room) Shin-Yurigaoka General Hospital Emergency Center Toshitaka Ito, Takaaki Nakano CIECER 0 CIECER

• #2.

  What is CIECER ? CIECER is a systematic approach to provide initial care to the patient in the ER setting. CIECER 1

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  Principles of this course: recognize the necessity of resuscitation recognize and act on the Emergen“C” / Emergen“CNS” assess the patient’s anatomic status after taking the patient history CIECER 2

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  How to assess the patient: CIECER 3 Necessity of resuscitation Search for abnormal findings in the body and begin treatment

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  What is resuscitation in the ER setting? CIECER 4 To prevent death! To relieve psychologic distress Resuscitation ≒ First aid ＜What is resuscitation?＞ Restoring life to an acutely ill patient with cardiopulmonary arrest that is caused by disease, injury, foreign body airway obstruction, etc. Recovery from asphyxiation CPR = cardiopulmonary resuscitation

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  Essential Physiologic Functions CIECER 5 Oxygen Delivery of Oxygen Intake of oxygen Airway Circulation CNS Oxygen Breathing Order of breathing

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  HyperthermiaHypothermia CIECER 6 Heat dissipation External cooling by air and massive transfusion Impaired heat production due to shock Hypothermia Coagulopathy and failure of compensatory mechanisms in the coagulation pathway Body Temperature Measurement and Care Heat Stroke DIC

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  Disruption in Essential Functions CIECER 7 Intake of oxygen Airway Obstruction Circulatory Failure Dysfunction of CNS Breathing Dysfunction

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  CIECER 8 ABCDE approach Airway Breathing Circulation Dysfunction of CNS Exposure Environment A B D C E Evaluate and restore in the following order:

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  Outline of the ABCDE Approach CIECER 9 Primary Primary Survey (PS) resuscitate if necessary First Impression

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  CIECER 10 Primary survey (PS) ・Sudden chest and/or back pain ・Sudden abdominal and/or back pain and shock Secondary Survey (SS) A C ECG, Echocardiography (or HIMAP） Chest and abdomen CT at the start of SS Measurement of cardiac enzymes（CK-MB, troponin）and D-dimer Emergen”C” ABC Stabilization （resuscitation） B D E

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  CIECER 11 Primary Survey (PS) GCS≦8 More than 2-pt decrease in GCS Signs of brain herniation: anisocoria, Cushing phenomenon Sudden hemiplegia Sudden headache Cramps D Confirm ABC stabilization（including airway management） Evaluate blood glucose and continue administration of anti-epileptic drugs Head CT at the start of SS A B C E Emergen“ CNS” Secondary Survey (SS) ABC Stabilization （resuscitation）

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  Diagnosis Using the ABC Approach CIECER 12 Clues for Diagnosis PS Abnormal findings SS

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  Information that can be obtained from EMS in Japan: Age & sex Chief complaint Uncomplicated physical symptoms Vital signs and consciousness level （It is not necessary in the case of an emergency / patient is in a calm state） The necessity of “load and go” Arrival time CIECER 13

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  Firstly Available Information: (Version for Trauma) M：Mechanism Mechanism of injury I：Injury Localization of injury S：Signs Signs of shock Necessity of “load and go” T：Treatment Treatment that has been initiated Estimated arrival time CIECER 14 M I S T

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  What is“ IntrinsicLoad and Go”? Abnormal A： Airway obstruction or severe stenosis, GCS≦ 8, and difficulties in airway management Abnormal B： Breathing abnormalities Respiratory rate （less than 10/min, etc.） Abnormal C： Cold sweaty skin, perspiration, tachycardia Abnormal D： Signs of brain herniation, GCS≦ 8 Abnormal pupillary response CIECER 15

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  Involves deceased passengers Ejection from vehicle Run over by car Victim(s) 5m from vehicle Severe vehicle crash Over 20 mins to arrive at crash site Vehicle rollover Large distance between bicycle-pedestrian Motor vehicle collision involving pedestrian(s) Machine injury / accident Crush injury of torso High-level fall injury CIECER 16 What is“ IntrinsicLoad and Go”? Mechanisms of High-Risk injury

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  What is“ Intrinsicload and go” Abnormal ABCD Severe facial injury Jugular vein distention, tracheal deviation, subcutaneous emphysema of neck or chest flail chest, left-right differences in breathing sounds, open pneumothorax Abdominal distention, muscle guarding pelvic fracture deformity, bleeding, swelling in both thighs, tetraplegia, dismemberment with shock penetration injury of the head / neck, trunk, inguinal region facial or tracheaｌ burns with airway obstruction CIECER 17

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  Information from EMS and the time of arrive must be shared with... Information must be shared with the nurse receptionist and nurse leader. Order a blood test if necessary Proceed with standard precautions Decide which department the patient will be admitted CIECER 18

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  Arrival of EMS Wait for the ambulance at the entrance of the ED. Give a precautionary knock on the rear door before opening the ambulance door. CIECER 19

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  First Impression Rapid evaluation of the ABCDE.　 2 or more functional abnormalities may indicate severe illness / injury. Report the findings to relevant staff! CIECER 20

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  CIECER 21 Primary Survey & Resuscitation Aim： rapid evaluation of physiologic function and supportive care First Impression Detailed ABCDE approach Administration of 100% oxygen 10～15L/min with monitoring, if necessary.

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  CIECER 22

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  Airway Evaluation,Securing the Airway: Observation speech, physical findings（see, listen, feel/touch） Apparatus for securing the airway Apnea, signs of upper airway obstruction, decreasing level of consciousness Securing the airway Mandibular fist method, suction, removal of foreign body Tracheal intubation, cricothyrotomy CIECER 23 A

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  Abnormal Speaking difficulties Dyspnea Wheezing during inspiration Signs of distress (tears, pallor, anguish) Muffled voice Orthopnea Expiration with remarkable force Retractive breathing CIECER 24 A

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  Respiratory Evaluation and Treatment:(neck/chest evaluation) Observation Inspection Respiratory rate, the use of respiratory muscles, swelling/deformities of the neck, flail chest, left-right differences in chest movement, open wound, jugular vein distension Auscultation, Percussion Left-right differences Palpation Tracheal deviation, subcutaneous emphysema, tenderness, flail chest Evaluation by tests SpO2, Chest X-ray CIECER 25 B

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  Abnormal Dyspnea Tachypnea Subcutaneous emphysema Left-right differences in breathing sounds Left-right differences in percussion Tracheal deviation Decreasing SpO2 Cyanosis CIECER 26 Suspected 　Tension pneumothorax or 　 　Tension hemothorax　 Administration of oxygen Securing the trachea: 　Tracheal intubation 　Cricothyroid ligament puncture 　Cricothyroid ligament Incision Chest tube drainage Hypoxia Dehydration, anemia Metabolic acidosis B

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  Circulatory Evaluation, Resuscitation, and Hemostasis: Observation＜early recognition of shock without measuring blood pressure＞ Pulse rate, skin findings, Capillary refill time, consciousness　　　　 Blood pressure, Monitoring ECG Resuscitation Compression hemostasis of external bleeding Secure an IV line (more than two） Begin early infusion therapy （1-2Ｌ、20ml/kg） Evaluate the patient’s reaction to early infusion therapy CIECER 27 C

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  Emergency Three Actions to Perform: ECG, echocardiography（or HIMAP） Chest/abdominal CT at the start of SS Measurement of cardiac enzymes （CK-MB, troponin） and D-dimer CIECER 28 Sudden chest/back pain, Sudden abdominal /back pain, and shock: C

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  Emergency （the next action） In the case of a suspected acute aortic dissection/rupture of the thoracoabdominal aorta, consult a cardiovascular surgeon immediately. In the case of a suspected myocardial infarction, consult a cardiologist In the case of a suspected intraperitoneal bleeding , consult a surgeon or radiologist CIECER 29 C

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  Emergency CNS Hemiparalysis GCS≦8 GCS decrease ≧2 Anisocoria, signs of herniation Seizure Thunderclap headache CIECER 30 Three Actions to Perform: ABC stabilization （including tracheal intubation） Evaluate blood glucose and continue administration of anti-epileptic drugs. Head CT at the start of SS

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  Emergency CNS （The next action） In the case of hypoglycemia: After securing vascular access, administer 50% glucose 40ml IV In the case of cerebral hemorrhage or subarachnoid hemorrhage, consult a neurosurgeon If the head CT reveals no remarkable abnormal findings, consult a neurologist and progress to NIHSS. In the case of status epilepticus, continue the administration of anti-epileptic drugs. Prepare for tracheal intubation. If any other cause of injury is conceivable, proceed to the Secondary Survey. CIECER 31

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  Exposure and Temperature Management CIECER 32 Undress the patient (inspection of body surface) Body temperature measurement Retain warmth Cover the body surface Body (surface/core) warming Warmed IV fluids E Low body temperature leads to→ hemorrhagic state, metabolic acidosis, abnormalities in coagulation

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  AMPLE:Patient History A：Allergy M：Medication Current prescription(s) Over-the-counter drugs P：Past Medical History Pregnancy L：Last meal E：Event ： Mechanism of injury Present medical history CIECER 33

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  Aim：- to identify and diagnose the injury that affects the whole body as a system.- to decide whether radical treatment is needed. When: SS should be initiated upon the completion of the primary survey and resuscitation Key Elements: Determine the mechanism of injury and medical history. Evaluate the whole body. Continue evaluating the vital signs and consciousness level →when abnormalities are detected, reevaluate the vital signs and consciousness level →Return to the ABCDE when any abnormalities are detected. CIECER 34 Secondary survey

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  Secondary Survey is dependent on the presenting symptoms: Injuries Overdose (drug addiction) Abdominal symptoms Respiratory symptoms Cardiovascular symptoms Fever Disturbance in consciousness Dizziness Cramps/syncope Neurological abnormalities Headache Backache Weakness CIECER 35

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  CIECER 36 Look for lesions by questioning the patient, inspection, and palpation!! - sclera, conjunctiva （anemia, jaundice）, - pupillary response (diameter), light reflex, - eye movement, ptosis, exophthalmos - hearing impairment, - focal tension, bruit, dry skin, - oral cavity, bit tongue, injury, halitosis Secondary Survey：Head, Face

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  CIECER 37 Secondary Survey：Neck - bruit, - common carotid artery palpation, - goiter, nuchal rigidity,　　　　　 - jugular vein distention, - tracheal deviation, - lymphadenopathy （neck, posterior auricle, supraclavicular）

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  CIECER 38 Secondary Survey：Chest Look for lesions by questioning the patient, inspection, and palpation!! - heartbeat, - breathing sounds - percussion, palpitation, - left-right differences in chest movement ＋Ultrasound examination

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  CIECER 39 Secondary Survey：Abdomen Look for lesions by questioning the patient, inspection, palpation, and rectal examination!! - abdominal inspection（flat, soft）, - muscle guarding, - swelling of organs, 　　 - abdominal distention, ascites, tenderness, recoil pain, - pulsatile mass ＋ Ultrasound examination Begin palpation from a location that is away from the painful region.

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  CIECER 40 Secondary Survey：Pelvis Look for lesions by questioning the patient, inspection, palpation, and rectal examination!! - pelvic distress, - tenderness, redness, - swelling of inguinal region / scrotum - rectal examination in the case of a suspected pelvic fracture / spinal cord injury Urinary catheter placement may be indicated.

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  CIECER 41 Secondary Survey： Bone & Skeletal Muscle edema, swelling, redness, muscle strength pain with movement perception, swelling of joints ability to walk

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  CIECER 42 Secondary Survey： BackDo not forget the survey of the back! Log-roll method（injured side should be face-up） ●spinal cord injury ●back stab wound Contraindicated in the case of a suspected unstable pelvic fracture → flat lift Tapping pain, redness, tenderness

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  Secondary Survey：Neurological Findings Pupillary response / appearance light reflex, cranial nerves, sensory function, paralysis (include NIHSS), coordination, ataxia, walking ability CIECER 43

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  Subsequent Secondary Surveys CIECER 44 Surveys: Conduct multiple surveys to determine the possible differential diagnoses. (Document all evaluations / survey results on medical record.) Diagnosis and Plan: Document the preliminary diagnosis and treatment. Document the plan of care (hospitalization, discharge outpatient care, etc.)

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  Important Considerations During Surveys and Treatment CIECER 45 Surveying the patient may exacerbate the patient’s condition: During transport within the hospital In the radiology room → reevaluate the ABCDE whenever the patient’s condition changes or worsens Avoid fixating on certain test results or diagnoses that may cause a delay in the transfer of the patient to another facility or consultation with other specialists.