Thursday, July 31, 2014

Resuscitation in the ED: Beyond the ABCs

Reuben Strayer, MD
, assistant clinical professor of emergency medicine at Mount Sinai Hospital in New York City, shares his expanded resuscitation mnemonic for the critical first 5 minutes. This talk originally appeared on and is lightly edited here. We last featured a talk by Strayer from AAEM 2014 about 10 ways to safely push ketamine in the ED.
Approaching a critically ill patient can be nerve-racking, and when your nerves are racked it can be hard to remember what to do. However, when you remember what to do, your nerves get less racked. So, I'm going to present a top-down approach to resuscitation that uses an expanded ABC's mnemonic to jog your memory and unrack your nerves:
DC3, A through J
For many years now, I go through this sequence in my head every time I'm confronted with a critically ill patent, and it makes me calm and organized, and a better doctor.
D for Danger
Danger to you the provider. Is it safe to approach the patient? In the emergency department this usually means protecting yourself from body fluid or airborne infectious diseases. Occasionally, there may be other concerns like the patient having something dangerous on their clothes or skin requiring decontamination. We deal with agitated or potentially violent patients all the time.
Like many of these bullet points, this is a talk unto itself, but from the perspective of resuscitation, if a critically ill patient is too agitated to be properly assessed, it is an absolutely crucial lifesaving maneuver to immediately and aggressively sedate.
There are a variety of effective agents I recommend: Droperidol, midazolam, and ketamine. If an IV is not yet available the agents should be given IM or IO.
The first C in C3 is "Call for help," move the patient to resus, call for your defibrillator, crash cart, airway cart, or whatever else is indicated. In big centers, you generally want more nurses and tech than usually show up and fewer doctors than usually show up.
Now that everyone is in the room you have to get them to be quiet. The second C is "Calm." Noise and shouting raise the ambient catecholamine level which makes it harder to take care of the patient. A forceful "Quiet please!" is usually all that's necessary to take everyone down a few notches. In big centers, there are usually too many people in the resus room when the patient arrives. Big resus cases are good for learning and occasionally someone in the peanut gallery has a good idea -- occasionally -- so I don't like to ask folks to leave the room.
Get them away from the action by announcing something like, "If you are not directly taking care of the patient please move to the perimeter of the room." If there is an orthopedist hanging out, he won't know the word "perimeter," so try "Please move away from the bed."
This is the time to determine who the resus leader is; if you're not sure, maybe it's you. All right, now that we've established the conditions in which the patient can be properly resuscitated, it's time to resuscitate the patient.
The third C in C3 stands for "Cardiac Arrest." Cardiac arrest has to be recognized straight away and is surprisingly easy to miss especially in a patient who arrives intubated by EMS. The first two priorities in cardiac arrest areimmediate uninterrupted high-quality chest compressions and defibrillation of v-fib and pulseless v-tach.
Cardinal ABCs
Now, we start in with the cardinal ABCs and A is of course "Airway." Our question is whether the patient needs an airway intervention. To answer this question, start with the patient's voice. The patient speaking comfortably with a normal voice is very unlikely to require an airway maneuver in the immediate term. Patients who are not speaking, demonstrate a patent and defended airway by handling their secretions.
Drooling and gurgling, coughing and gagging, are your clue that you may have an airway problem. But do not elicit a gag reflex as a way to test airway integrity. It's inaccurate and may induce vomiting and is exactly the person you do not want to vomit. Stridor is another sign and patients with a good level of consciousness and an airway obstruction may assume an airway posture, which is sniffing position.
Sometimes, the patient just needs repositioning of the head, but this is also the time to suction out the oropharynx, place oral or nasal airways or even an LMA if indicated, and determine if intubation is required or soon will be. If so, call for medications if needed and prepare for definitive airway management.
Move on to "Breathing," which is oxygenation and ventilation. Do yourself and patients a favor and put a nasal cannula on every critically ill patient from the start and then any additional oxygen or ventilation on top of that. Unless the patient is truly crashing, I apply the nasal cannula and keep the wall-oxygen off until I get a room air oxygen saturation, which provides much more information about oxygenation and ventilation than a saturation with supplemental oxygen.
Ventilate the patient if needed. Your initial exam maneuvers are pulse oximetry, respiratory rate, effort, and then breath sounds. Auscultating the lungs is a reflex action taken by many junior clinicians as a response to a distressed patient. I think that's because it makes it seem like you're doing something when you don't know what to do. In most cases, listening to the lungs is not helpful and is always less important than evaluating oxygenation and ventilation using respiratory effort and saturation. What you're listening for is air entering both sides, and the presence of wheezes or crackles. This should take no longer than seven second -- 3.5 seconds per lung.
Therapies to consider in the first five minutes relevant to breathing include needle finger or tube or ostomy, albuterol, epinephrine, or nitro. Call for a portable chest x-ray if indicated.
The initial "Circulation" priorities include immediate establishment of either intravenous or intraosseous access, measurement of heart rate and blood pressure, which is usually accomplished by putting a patient on a monitor, and the assessment of the adequacy of perfusion, feel for pulses, and assess the skin at the hands and feet. Immediate therapies to support circulation include IV fluids and uncrossed matched blood products and call for EKG when indicated.
Hyperkalemia is so common and so dangerous it should specifically be considered in a primary survey. C can also stand for "Calcium" in a critically ill dialysis patient with bradycardia or a wide complex rhythm.
D for Neurologic Disability
In the first phase of resuscitation, this calls for four maneuvers. Assessment of level of consciousness, usually using a responsiveness scale like GCS as well as the quality of the patient's mentation. Agitation or confusion are as important as decreased consciousness. Measure the pupils and their response to light. Determine movement at four extremities and rule out or treat hyperglycemia.
We don't have a problem with getting to do head CTs, but to be complete I must mention that this is the time to consider a STAT brain scan.
E for Exposure
Remove all clothing. And visualize every inch of skin. It is ideal if you can get this done at the initial assessment. It really sucks when the ICU team comes down and pulls the nitro patch off your hypotensive patient. Have someone check the pocket for pill bottles, the pacemaker wallet card, or a summary of their medical history. Use the opportunity to do a rectal temp if needed, and initiate active cooling or warming if indicated.
F Stands for Family and friends
If the history isn't clear, get a better story. Ask about goals of care, if appropriate. Give the patient's family an update on a patient's status within a cautious prognosis. If you say, "I'm very concerned about grandma," and she does well that's not a big problem. In fact, it makes you look like a very skillful doctor. If you say, "Grandma is doing great," and the next time the family sees her they have to unzip a body bag, you're not going to get a rave review on If the family is outside the resus area, ask them if they wish to be present during the resuscitation.
G Is for Analgesia
Do not forget to treat your patient's pain. I have looked back at many resuscitations and realized the only thing I did that actually helped the patient was morphine. Give it early and in appropriate doses: IV, IM or IO. If hypertension is a concern use fentanyl. If you don't have a line in a child, intranasal fentanyl is very effective. And for the patient in severe pain, adding an analgesic dose of ketamine is magic.
H Is for HCG
This is easy to forget and pregnancy changes everything. The bedside urine HCG assay works just as well with two drops of whole blood or capillary blood from a finger stick. In the clearly gravid female who is hypotensive, push the uterus to the left, And if she is dying or dead, consider a perimortem C-section. Don't worry about how many weeks or how many minutes mom has been arrested -- perimortem cesarean section is for mom more than for baby.
I Is for Infection
Consider whether the patient should be isolated, and do not delay the administration of broad spectrum antibiotics in a patient thought to be critically ill from an infection. If source control is required, this needs to be done expeditiously.
J Is for Ultrasound Jel
The last part of the first 5 minutes is ultrasound. Let me know if you have a better way of getting the word ultrasound to work with the letter J. All patients with hypotension of unclear etiology should have a comprehensive point of care ultrasound for shock. There is an ever expanding list of indications of point of care ultrasound. Get the probe on the chest early in a critically ill patient.
There is another C I left out: If you are using a mnemonic to study for oral board exams, add one more C after Cardiac Arrest -- as in C for spine immobilization collars. These have minimal if any utility in few, if any patients, and certainly cause harm, but we're probably a long way away from standard of care catching up to science in this domain. So if you're resuscitating a patient while wearing your best suit seated uncomfortably in a hotel across from somebody with gray hair who doesn't want to be there any more than you, add a C for C spine precautions.
In real life for the first 5 minutes of resuscitation: DC3, A through J.

No comments:

Post a Comment