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Rapid Primary Survey and Resuscitation

As usual, the following blog post is available in podcast form! We are "Med On The Go" in iTunes, Google Play, and Podbean. www.medonthego.podbean.com. And if you enjoy the podcast and notes, please sponsor us! Register at https://patron.podbean.com/medonthego and as a patron you'll enjoy thank you emails, mentions in the podcast, and more exclusive material!

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This is an important topic and one that is quite personal to me. I have had the unpleasant experience of witnessing motor vehicle accidents and a suicide incident, and I have had to conduct rapid primary survey. There is a lot of information to cover, but trust me, when you are the first source of help on the scene a lot of it actually comes back naturally (adrenaline helps a lot!) I’ve decided to cover rapid primary survey and resuscitation together because they are usually carried out at the same time, followed by detailed secondary survey and then definitive treatment.

Rapid Primary Survey (RPS):

·      Airway maintenance with C-spine control

o   Always assume cervical injury in trauma patients and immobilize with collar. Requirements for clearing C-spine include NO midline tenderness, NO focal neurological deficits, and NOT distracting factors like intoxication or altered level of consciousness

o   Assess for signs of obstruction—agitation, confusion, “universal choking sign”, respiratory distress, noisy breathing, failure to speak, dysphonia, cyanosis

o   SECURE AIRWAY

§  Basic airway management

·      Head-tilt (if C-spine injury not suspected) or jaw thrust to open the airway

·      Sweep and suction to clear mouth of foreign material

§  Temporizing measures

·      Nasopharyngeal airway if conscious

·      Oropharyngeal airway if unconscious

·      “Rescue” airway devices such as laryngeal mask airway

§  Definitive airway management

·      Endotracheal intubation with in-line stabilization of C-spine

o   Indications for intubation

§  Patient unable to protect airway GCS < 8

§  Inadequate oxygenation with spontaneous respiration (O2 sat < 90% with 100% O2 or rising pCO2)

§  Profound shock

§  Anticipatory—trauma, OD, CHF, asthma, COPD, smoke inhalation injury

§  Anticipated transfer of critically ill patients

o   Orotracheal—usually done with rapid sequence induction

o   Nasotracheal—better tolerated in conscious patient

o   Contraindicated with basal skull fracture* or any supraglottic/glottic pathology that would preclude successful intubation

o   Does not provide 100% protection against aspiration

·      Surgical airway such as cricothyroidotomy

·      Drugs can be delivered via ETT (NAVEL)—naloxone, atropine, ventolin (salbutamol), epinephrine, lidocaine

·      Breathing and ventilation

o   Classic “look, listen, feel” and assess need for resuscitation

o   Assess respiratory rate, oximetry (< 90 warrants intervention), ABG

o   Management (in order of increasing FiO2)

§  Nasal prongs

§  Simple face mask

§  Non-rebreather mask

§  CPAP/BiPAP

§  Venturi mask—used to precisely control O2 delivery

§  Bag-valve mask and CPAP to supplement inadequate ventilation

·      Circulation (pulses, hemorrhage control)

o   Assess pulse and need for CPR

o   ALWAYS watch for sign of SHOCK while doing the primary survey**

§  Early signs—tachypnea, tachycardia, narrow pulse pressure, reduced capillary refill, cool extremities, and reduced central venous pressure

§  Late signs—hypotension and altered mental status, reduced urine output

Class	I	II	III	IV
Blood loss	< 750cc	750~1500cc	1500~2000cc	> 2000cc
% volume	< 15%	15~30%	30~40%	> 40%
Pulse	< 100	> 100	> 120	> 140
BP	Normal	Normal	Decreased	Decreased
RR	20	30	35	> 45
Capillary refill	Normal	Decreased	Decreased	Decreased
Urinary output	30cc/hr	20cc/hr	10cc/hr	None
Replacement	Crystalloid	Crystalloid	Crystalloid + blood	Crystalloid + blood

o   Fluid replacement

§  1~2L bolus of crystalloids (normal saline, Ringer’s, Dextrose) with large bore IV (warm if possible)

§  Colloids (albumin, FFP) keeps fluids within vessels and less permeated into interstitial space, leading to less total fluid volume required (40~60% reduction of crystalloids), less tendency of fluid overload, and shorter resuscitation time.

§  Packed RBC if hypotensive or if shock persists—blood should ideally by cross-matched or type-specific but when not possible transfuse O-negative in children and women of childbearing age; transfuse O-positive in all others.

§  If patient doesn’t respond to fluids/transfusion consider active internal bleeding (usually from ruptured spleen) and send for surgical intervention.

§  Maintenance rate per hour = weight (kg) + 40

o   Apply direct pressure over any wounds, elevate extremities, and do not remove any impaled objects.

·      Disability (neurological status)***

o   Assess consciousness using AVPU or GCS

§  AVPU (Alert Voice Pain Unresponsive)

·      Alert: The patient is fully awake (although not necessarily oriented). = GCS 15

·      Voice: The patient makes some kind of response when talked to, which could be in any of the three component measures of eyes, voice or motor. = GCS 12

·      Pain: The patient makes a response to pain. = GCS 8

·      Unresponsive: Nonresponsive even to pain. = GCS 3

§  Glascow Coma Scale

Eyes	Verbal	Motor
4 Spontaneous	5 Answers questions appropriately	6 Obeys commands
3 To voice	4 Confused, disoriented	5 Localizes to pain
2 To pain	3 Inappropriate words	4 Withdraws from pain
1 No response	2 Incomprehensible sounds	3 Decorticate (flexion)
	1 No verbal response	2 Decerebrate (extension)
		1 No response

·      Exposure (go over entire body to ensure no injury is missed) and Environment (temperature control)

o   Undress patient completely and assess entire body for injury; logroll to examine back

o   Digital rectal exam to assess internal bleeding

o   Keep patient warm with a blanket or radiant heaters to avoid hypothermia

o   Keep care providers safe from contamination and combative patient

·      The above needs to be continually reassessed every 5~15 minutes during secondary survey

·      Monitoring

o   O2, BP, ECG

o   Foley catheter and NGT if indicated (NO NGT if significant mid-face trauma or basal skull fracture; NO FOLEY if blood at urethral meatus, scrotal hematoma, high-riding prostate on digital rectal exam)

·      Tests and investigations—CBC, electrolytes, BUN, creatinine, glucose, amylase, INR/PTT, beta-hCG, toxicology screen, cross and type

·      SIX KEY INJURIES TO EXCLUDE DURING PRIMARY SURVEY (“At This Moment Find Ominous Conditions”)

o   Airway obstruction

o   Tension pneumothorax

o   Massive haemothorax

o   Flail chest

o   Open pneumothorax

o   Cardiac tamponade

*Tell-tale signs of base of skull fracture:

·      CSF leak from nose and/or ear

·      Bilateral periorbital bruising (“raccoon eyes”)

·      Haemotympanum and bruising behind the ear (Battle’s sign)

**Treat shock as hemorrhagic shock unless proven otherwise. The following is a general classification of various causes of shock:

Hypovolemic	Cardiogenic	Distributive	Obstructive
Hemorrhage Severe burns High output fistulas Dehydration	Myocardial ischemia Dysrhythmias CHF Cardiomyopathies Cardiac valve problems	Septic Anaphylactic Neurogenic	Cardiac tamponade Tension pneumothorax Pulmonary embolism Aortic stenosis Constrictive pericarditis

***Toronto Notes 2016 includes the examination of pupils during this stage.

Overdose Emergencies

Drug overdose has been a huge topic in Canada recently. Opioid painkiller addiction and fentanyl use have constantly been on TV, either as incidents leading to news reports or documentary/journalism pieces bringing about awareness. Not to mention tabloids blasting the alleged details of various actors’ drug rehab fails. So the issue of drug overdose is really not a new one. Below are some general guidelines to follow.

If the patient is alert enough, try to take as much history as possible: which substance did they use? How much did they use? Via what route? How much time has passed since usage? It’s also important to document the factors that can determine outcome, such as age, weight, underlying medical problems, and other medications. Remember to ask about suicide ideation and intention.

Always suspect overdose when:

·      Altered level of consciousness/coma

·      Young patient with life-threatening dysrhythmia

·      Trauma patient

·      Bizarre or puzzling clinical presentation

Manage DRABC first. DRAB is the same as conventional protocol, but D can be split into three different meanings: drugs, draw bloods, and decontamination (decrease absorption or increase elimination). E stands for examine the patient and exposure to specific toxidromes. F stands for full vitals monitoring (e.g. ECG, urinary catheter, X-rays); conduct physical examination with emphasis on vital signs, GCS, and pupils. The definitive treatment depends on what the patient has overdosed on.

Universal antidotes (remember DON’T):

D—dextrose

O—oxygen

N—naloxone

T—Thiamine (must give this BEFORE dextrose)

Naloxone administration may cause opioid withdraw in chronic users. Mild symptoms of opioid withdraw may include lacrimation, rhinorrhea, diaphoresis,

yawning, piloerection, hypertension, and tachycardia. Severe withdraw symptoms include hot and cold flushes, arthralgia, myalgia, abdominal cramping, and nausea and vomiting.

Blood work should include:

·      General: CBC, BUN/creatinine, glucose, INR/PTT, osmolality

·      ABG and oxygen saturation

·      Protein and albumin

·      Lactate

·      Ketones

·      Liver enzymes

·      Creatine kinase

·      Electrolytes and especially the following

o   Calcium

o   Magnesium

o   Phosphophate

·      Drug levels (can guess based on history and clinical findings)

o   Acetylsalicylic acid (ASA)

o   Acetaminophen

o   Ethanol

o   Urine screens also available

o   Remember negative toxicology screen does not rule out a toxic ingestion

Decontamination and enhanced elimination really depends on the area affected. For ocular, use saline irrigation to neutralize pH; alkali exposure requires ophthalmology consult. Dermal decontamination requires the removal of patient’s clothing (wear protective gear!), brush off toxic agents, and irrigate all external surfaces. For gastrointestinal decontamination, a single dose of activated charcoal can be given; beware that lithium, iron, alcohols, lead, and caustics are NOT absorbed by activated charcoal. Slow whole bowel irrigation (500ml in adults and slowly increase rate hourly) can be carried out.

Hemodialysis is use for the ingestion of methanol, ethylene glycol, salicylates, lithium, phenobarbital, chloral hydrate, theophylline, carbamazepine, valproate, and methotrexate. It can also be used in those who have impairment in normal mode of elimination.

Physical examination:

·      Vital signs (including temperature)

·      Skin (needle tracks, color) and mucous membranes

·      CNS, pupils

·      Odor

·      Head-to-toe survey

o   C spine

o   Signs of trauma, seizures (incontinence, tongue-biting), infection (meningismus), chronic alcohol/drug abuse (track marks, nasal septum erosion)

·      Mental status

Below is a guide to differential diagnosis based on clinical laboratory findings. It’s good to know, but I don’t think it’s absolutely necessary to commit to memory.

Below are two tables showing some toxidromes. I think it’s useful as a reference, but once again I don’t think it’s necessary to commit to memory because it’s just far too much and too complex.

Definitive treatment involves giving specific antidotes and treatments.

Substance	Antidote
Acetaminophen	N-acetylcysteine
Anticholinergics	Physostigmine
Benzodiazepines	Flumazenil
Calcium channel blockers	Calcium chloride, calcium gluconate
Cyanide or nitrate	Methylene blue
Digoxin	Digoxin immune fab
Heparin	Protamine sulfate
Iron	Deferoxamine
Insulin	Glucagon
Lead	Succimer
Opioids	Naloxone or nalmefene
Warfarin	Vitamin K

Warfarin overdose treatment is dependent on the INR of the patient.

<5.0                Hold warfarin, observation, and serial INR/PT

5.1~9.0          If no risk of bleeding, hold warfarin for 1~2 days and reduce maintenance dose. If risk of bleeding, vitamin K 1~2mg PO.

9.1~20.0        Hold warfarin, vitamin K 2~4mg PO, serial INR/PT, additional vitamin K if necessary

>20.0              Hold warfarin, vitamin K 10mg IV over 10min, increase dosing every 4 hours if needed

Lastly, here are some extra random bits of information that may prove to be useful—but I don’t think it’s necessary to commit this to memory.

As usual, you are most welcome to contribute further by posting on comment section below. Any suggestions for future episodes are also welcome. 

This blog post is available in podcast form! Look for "Med On The Go" on iTunes, Google Play, and Podbean or at www.medonthego.podbean.com.