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Assessment in the Emergency Department

Assessment in the Emergency Department. Dr Jeff Keep Consultant in Emergency Medicine & Major Trauma King’s College Hospital. Time Critical. Thrombolysis has elevated acute stroke to a time-critical condition

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Assessment in the Emergency Department

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  1. Assessment in the Emergency Department Dr Jeff Keep Consultant in Emergency Medicine & Major Trauma King’s College Hospital

  2. 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.

  3. 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.

  4. 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.

  5. Time-Critical Essentially, a serious condition in which there is rapid deterioration with time unless it is stopped.

  6. Emergency Systems Emergency systems are designed and developed to manage Emergent and Time-Critical situations or events

  7. 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

  8. 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

  9. 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

  10. 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

  11. Easy-Peasy? • The more links in the chain, the more potential places that it can break • Chinese Whispers...

  12. Easy-Peasy? • Airway compromise • Aspiration • Hypertension • Arrhythmia • Altered conscious level • Coagulopathy – on Warfarin?

  13. Easy-Peasy? • Neurological Stroke Mimic • Variable Symptoms / Signs • Head Injury • Metabolic Injury • Psychiatric Illness

  14. The Solution?

  15. Almost...

  16. The solution

  17. 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?

  18. Stroke Doctor • Confirm FAST positive & time of onset • Look for inclusions / exclusions • More in-depth history & examination

  19. ED doctor • ABC assessment • Interpret ECG • Contact CT and organise scan

  20. ED Technician / FY2 • IV access • Routine bloods • Rapid INR test if on warfarin

  21. ED / Stroke Nurse • ABC assessment • Attach directly to transport monitor • Perform ECG • Accompany patient to CT

  22. Stroke Unit Sister • Aware of potential admission • Able to organise bed • Able to come and assist

  23. Radiographer • Empty the scanner • Prepare for investigations

  24. Receptionist • Book in patient immediately onto system

  25. Porter • Check oxygen cylinder • Transport patient

  26. What’s next? • Multiple patients • Haemorrhagic stroke • Airway problem • Not a stroke

  27. Focus on the Team

  28. Possible members • Anaesthetist • Physician • Stroke Nurse • Radiologist • Neurosurgeon

  29. Multiple Strokes

  30. 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

  31. Thank you for listening...

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