Download - Assessment in the Emergency Department
Assessment in the Emergency Department
Dr Jeff KeepConsultant in Emergency Medicine & Major Trauma
King’s College Hospital
Time Critical
Thrombolysis has elevated acute stroke to a time-critical condition
Comparable to acute MI, Major Trauma, Severe Sepsis / Septic Shock, Acute Severe Asthma etc.
Definition?• crit·i·cal (krt-kl) adj. 1. Inclined to judge severely and find fault.• 2. Characterized by careful, exact evaluation and judgment: a critical
reading.• 3. Of, relating to, or characteristic of critics or criticism: critical acclaim; a
critical analysis of Melville's writings.• 4. Forming or having the nature of a turning point; crucial or decisive: a
critical point in the campaign.• 5. a. Of or relating to a medical crisis: an illness at the critical stage.• b. Being or relating to a grave physical condition especially of a patient.• 6. Indispensable; essential: a critical element of the plan; a second income
that is critical to the family's well-being.• 7. Being in or verging on a state of crisis or emergency: a critical shortage of
food.• 8. Fraught with danger or risk; perilous.
Definition?• crit·i·cal (krt-kl) adj. 1. Inclined to judge severely and find fault.• 2. Characterized by careful, exact evaluation and judgment: a critical
reading.• 3. Of, relating to, or characteristic of critics or criticism: critical acclaim; a
critical analysis of Melville's writings.• 4. Forming or having the nature of a turning point; crucial or decisive: a
critical point in the campaign.• 5. a. Of or relating to a medical crisis: an illness at the critical stage.• b. Being or relating to a grave physical condition especially of a patient.• 6. Indispensable; essential: a critical element of the plan; a second income
that is critical to the family's well-being.• 7. Being in or verging on a state of crisis or emergency: a critical shortage of
food.• 8. Fraught with danger or risk; perilous.
Time-Critical
Essentially, a serious condition in which there is rapid deterioration with time unless it is stopped.
Emergency Systems
Emergency systems are designed and developed to manage Emergent and Time-Critical situations or events
NNT (Lansberg, Stanford University)
• 0-90 minutes NNTB = 3.6• 91-180 minutes NNTB = 4.3• 181-270 minutes NNTB = 5.9• 271 – 360 minutes NNTB = 19.3
NNT (Lansberg, Stanford University)
• 0-90 minutes NNTB/H = 3.6/65• 91-180 minutes NNTB/H = 4.3/38• 181-270 minutes NNTB/H = 5.9/30• 271 – 360 minutes NNTB/H = 19.3/14
Therefore gives the cut-off of 4.5 hours
4.5 hours
• But we do not have this much time• We must act as soon as we can• In London we have a target of 30 minutes
‘Door-to-Needle’• Which means that if a patient has a
thrombolysable stroke, they must be receiving thrombolysis within 30 minutes of arriving at the ED
The Chain of Survival
• Recognition of symptoms• Contact EMS (999)• Priority dispatch• EMS transport patient to the
right hospital• EMS pre-alert• Early recognition of
symptoms/signs• Early imaging• Early treatment
Easy-Peasy?
• The more links in the chain, the more potential places that it can break
• Chinese Whispers...
Easy-Peasy?
• Airway compromise• Aspiration• Hypertension• Arrhythmia• Altered conscious level• Coagulopathy – on Warfarin?
Easy-Peasy?
• Neurological Stroke Mimic• Variable Symptoms / Signs• Head Injury• Metabolic Injury• Psychiatric Illness
The Solution?
Almost...
The solution
Stroke Team
• What is a team?• Who should be in a stroke team?• What is the role of a team leader?
• What is the role of a team member?
Stroke Doctor
• Confirm FAST positive & time of onset• Look for inclusions / exclusions• More in-depth history & examination
ED doctor
• ABC assessment• Interpret ECG• Contact CT and organise scan
ED Technician / FY2
• IV access• Routine bloods• Rapid INR test if on warfarin
ED / Stroke Nurse
• ABC assessment• Attach directly to transport monitor• Perform ECG• Accompany patient to CT
Stroke Unit Sister
• Aware of potential admission• Able to organise bed• Able to come and assist
Radiographer
• Empty the scanner• Prepare for investigations
Receptionist
• Book in patient immediately onto system
Porter
• Check oxygen cylinder• Transport patient
What’s next?
• Multiple patients• Haemorrhagic stroke• Airway problem• Not a stroke
Focus on the Team
Possible members
• Anaesthetist• Physician• Stroke Nurse• Radiologist• Neurosurgeon
Multiple Strokes
Summary
• Time-critical illness needs a structured, safe approach
• Does not mean we run around quickly• Develop a Team approach – many people
with few, achievable tasks within their comfort zone
• Regular meetings – build bonds, review practise, learn
Thank you for listening...