Triage

- Manage resources, inflow/outflow of patients

- Philippines adapted the ESI system

Primary survey
- Identify life-threatening conditions
- ABCDE
- Airway
- Breathing
- Circulation
- Disability
- Exposure
- Also include Pain Scale

Airway
- Talk to the patient to assess airway, could also be used to assess disability
- Cervical spine injury - usually for trauma patients
- X + ABCDE
- X = neck stabilization using hard cervical collar
- Depending on mechanism of injury
- If there is any sign of injury above the clavicles, assume there is cervical spine
injury
- Abnormal: Signs of obstruction
- Not able to talk normally
- Stridor - upper airway obstruction)
- Do not perform blind finger sweep
- Head tilt, chin lift or Jaw thrust maneuver
- Snoring - tongue is obstructing
- Head tilt, chin lift
- Gurgling sounds (blood, secretions)
- Suction
- Decreased level of consciousness
- Interventions:
- Oropharyngeal airway device
- Nasopharyngeal airway device
- Contraindication: Facial trauma
- Nasotracheal airway device
- For patients that are awake, breathing
- Endotracheal intubation
- Cricothyroidotomy
- Temporizing measure: for 45 minutes only
- Early intubation
- Rapid sequence intubation - in ED
- Patient is unprepared
 - Rapid sequence induction - in OR
- Patient is prepared
- Mallampati score

Breathing
- Respiratory rate (N: 12-20/min)
- Pulse oximeter (N: >90% or ≥94%)
- Breath sounds
- Absent breath sounds: most dangerous
- Lung collapse (e.g., pneumothorax): no air movement
- Palpate the chest
- Flail chest: paradoxical movement, broken 2 ribs (?)
- Oxygenation (oxygen supplementation)
- NC - maximum 6 lpm (0.4 x RA + 20%)
- More on irritation
- Simple FM - maximum 8 lpm
- Usually for mouth breathers
- Non-rebreather FM
- Inflate with oxygen prior
- Can reach FiO2 to 80-100%
- Whole volume of inspired oxygen from the tank → pure oxygen
- Improved RR, SpO2
- Improved color (decreased pallor)
- Improved mental status
- Pneumothorax (unequal chest expansion)
- Needle thoracentesis - tension pneumothorax
- 4-5th ICS, AAL
- Should be high sitting
- CXR
- Point-of-care ultrasound
- Abnormal lung sliding (?)
- Dyspnea
- ESI 2 or higher

Circulation
- Assess BP
- BP 90/60 mmHg, but patient is known hypertensive
- Assess HR
- Assess CRT (N: CRT < 2 secs)
- Level of consciousness
- First compensation for low BP is increased HR
- Diaphoresis, pain
- Diagnostics: ECG
- Intervention:
 - Hypotensive: 2 large bore IV line
- Fluid resuscitation
- Crystalloid (Plain NSS, Plain LR, balanced solution) - isotonic solution
- For trauma: Plain LR to prevent acidosis
- Always reassess patient!
- Check HR
- Check UO (i.e., so all patients need FC if for fluid resuscitation)
- UO: 0.5-1cc/kg/hr
- Breath sounds (check for congestion)
- Neck vein distention
- Check pulses
- Leg raise maneuver
- Improve HR, BP (increased by 10 mmHg)
- Ultrasound
- Check IVC, if collapsible, fluid responsive
- B lines
- Wet lungs
- Can detect earlier than breath sounds, neck vein distention
- Cardiac monitor
- Intervention: usually fluids first before blood transfusion (give STAT O+)

Disability
- Check GCS
- Technically for head trauma
- GCS 8,9 - do intubation
- Level of consciousness
- Check CBG (for altered mental status)
- Check for encephalopathy
- Check pupils
- Mortal sin: Intubating someone hypoglycemic!

Exposure
- Check everything
- Temperature

Secondary survey
- Address life-threatening problems first before proceeding with secondary survey
- Targeted history
- SAMPLE
- Symptoms
- Allergy
- Medications
- Past Illness
- Last Meal
 - Events

Priority problems

ECG

Oxygen
- Depends on SpO2
- Target: >94% SpO2

Intravenous fluid
- Reassess patient
- Improved HR, improved diaphoresis

Medications
- Aspirin: 160-320 mg tablet
- Clopidogrel (pro-drug)
- Filipinos are poor metabolizers
- Ticagrelor
- Nitrates

Interventions (MONA)
- Morphine
- For congested patients, increase pre-load
- Contraindications: hypotension
- Oxygen
- If less than 90
- Hyperoxygenation: can result in free radical production
- Nitrates (sublingual)
- For ongoing chest pain
- Contraindications: hypotension
- Caution: inferior wall MI
- Antiplatelets
- Statins
- Anti-inflammatory because the plaque disintegrated
- Beta-blockers
- Contraindications: hypotension
- Low MW Heparin

Inferior wall infarction

- Fluid resuscitation
- Push fluids to the right side of the heart

PCI
 - In PGH, there is STEMI protocol
- Revascularize the heart as early as possible
- Time is muscle
- Gold standard: PCI
- Within 60 mins according to Sir

Fibrinolytics
- Streptokinase: usually allergenic
- RTPA