Chapter Two Monitoring Techniques and Procedures of Emergency Medicine Jia Xu The First Affiliated Hospital of College of Medicine, Zhejiang University

Chapter Two Monitoring Techniques and Procedures of Emergency Medicine

Jia XuThe First Affiliated Hospital of College of Medicine, Zhejiang University

Section One Monitoring the Emergency Patient


第十章发热：于学忠

Monitoring the Emergency Patient

1 Temperature (T) 1 Temperature (T)

2 Pulse (P) 2 Pulse (P)

3 Respiratory Rate (RR) 3 Respiratory Rate (RR)

4 Blood Pressure (BP) 4 Blood Pressure (BP)

5 Pulse Oximetry (SpO2) 5 Pulse Oximetry (SpO2)

6 Electrocardiography (ECG) 6 Electrocardiography (ECG)


1 TEMPERATURE

T

Temperature is an indication of

pathologic conditions.

The inability to maintain normal

body temperature is indicative of

a vast number of potentially

serious disorders


Pathology

heat production ＞

dissipation

Fever

exogenous pyrogen

endogenous pyrogen


Indications and Contraindications

Oral temperature

Rectal temperature

Axillary temperature

Estimated core body

temperature

Indications: cooperative adult or child Contraindications: uncooperative, hemodynamically unstable, septic, RR > 20.

Indications: ambulatory patients and children younger than 3. Contraindications: neutropenia and recent rectal surgery.

Indications: neonatal patients and when other sites are unavailable.


Interpretation



Oral temperature

Oral temperature

Rectal temperature

Rectal temperature

37.8°C or higher 38.0°C or higher

low sensitivity low sensitivity high specificityhigh specificity

for feverfor fever

low sensitivity low sensitivity high specificityhigh specificity

for feverfor fever

37.3°C or higher

rapid change with rapid change with blood temperatureblood temperature(e.g., open heart (e.g., open heart

surgery)surgery)

rapid change with rapid change with blood temperatureblood temperature(e.g., open heart (e.g., open heart

surgery)surgery)

accurate to accurate to reflect the body reflect the body core temperaturecore temperature

accurate to accurate to reflect the body reflect the body core temperaturecore temperature


Physiological Influencing Factors

activitythe use of antipyretics

environmental exposure

others

pregnancy

patient age

T


Pathological Influencing Factors

Infective

Fever

Fever

Non-infective Fever


Infective Fever

Systems Critical Emergent Nonurgent

Respiratory system bacterial pneumonia with respiratory failure

bacterial pneumonia, peritonsillar abscess, retropharyngeal abscess, epiglottitis

otitis media, sinusitis, pharyngitis, bronchitis, influenza, tuberculosis

Cardiovascular system endocarditis,pericarditis

Digestive system peritonitis appendicitis, cholecystitis, diverticulitis, abdominal abscess, pancreatitis,

colitis / enteritis

Urogenital system pyelonephritis, tubal ovarian abscess, pelvic inflammatory

cystitis, epididymitis, prostatitis

Nervous system meningitis, cavernous sinus thrombosis

encephalitis, brain abscess

Skin and soft tissue cellulitis, infected pressure ulcers, soft tissue abscess

Systemic diseases sepsis / septic shock, meningococcemia


Non-infective Fever

Critical Emergent Nonurgent

acute myocardial infarction congestive heart failure drug fever

pulmonary embolism / infarction dehydration malignancy

intracranial hemorrhage recent onset of seizures gout

stroke sickle cell disease sarcoidosis

neuroleptic malignant syndrome transplant rejection Crohn disease

thyroid crisis pancreatitis

acute adrenal insufficiency deep vein thrombosis

transfusion reaction

pulmonary edema


2 RESPIRATIONRESPIRATION

RR

An abnormality in respiration

may be a primary complaint or a

manifestation of other systemic

disease.


Interpretation

tachy

pnea

>24 times/min

pulmonary or cardiac diseases; acidosis, anemia, fever, stress, and drugs (such as stimulants and salicylates).

1 Respiratory Rates: 16-18 times/min

bradybrady

pneapnea

<12 times/min

intracranial hypertension, respiratory failure, and morphine poisoning.


Interpretation

2 Respiratory Pattern:

The normal breathing manner is in a rhythmic,

airway smooth and natural way.

brain lesions (cerebral cortex); congestive heart failure; respiratory depressant

meningitis, uremia and brain lesions (medulla);

pontine lesion

metabolic acidosis (diabetes, uremia)


Interpretation

3 Respiratory Amplitude:

inspiratory phase > expiratory phase:

intra tracheal foreign body and severe laryngitis;

Inspiratory phase < expiratory phase:

chronic obstructive pulmonary disease (COPD).


3 PULSEPULSE

P

Palpate the peripheral pulses to

yield clues about cardiac disease,

such as aortic insufficiency, and

information about the integrity of

the peripheral vascular supply.


Interpretation

1 Pulse Rate ： Consider the individual's physiology (e.g., athlete);

Consider whether a patient's abnormal pulse rate is

a primary or secondary condition (e.g., tachycardia

and fever);

Consider the medications that the patient may be

taking (e.g., digitalis compounds, β-blockers, and

antidysrhythmics) or the presence of a mechanical

pacemaker.


Interpretation

2 Heart Rhythm ：

irregular pulse ： atrial fibrillation or flutter.

apical cardiac sounds is frequently greater than

the peripheral pulse.


Interpretation

3 Pulse Amplitude and Contour ：

Early in sepsis, cardiac output increases and vascular resistance decreases, causing bounding pulses.

In advanced sepsis or septic shock, falling cardiac output and increased vascular resistance are seen, and pulses are diminished.

Important sign of left heart failure

hypertrophic obstructive cardiomyopathy

cardiac tamponade or pericardial constriction


4 ARTERIAL BLOOD ARTERIAL BLOOD PRESSUREPRESSURE

BP

Changes in arterial BP over time may

indicate the success of treatment or the

worsening of the patient's overall condition.

An abrupt reduction in the patient's arterial

blood pressure usually indicates the need for

immediate intervention or reconsideration of

therapy.


Interpretation

body posture, emotional or painful stimuli

agemales

vasoactive foods or medications,

others

environmental influences

the state of muscularcerebral activity

BP


Interpretation

1 Hypertension:

Adults are hypertensive if either the systolic or the diastolic

pressure consistently exceeds or mm Hg,

respectively.

Patients with hypertension require repeat measurement to

assess whether ED therapy is required.

140 90


Interpretation

2 Hypotension

Adults are hypotension if BP is lower than

90/60~50 mmHg.

It is commonlly observed in serious

diseases, such as shock, myocardial

infarction and acute cardiac tamponade.


Interpretation

3 Pulse Pressure:

The difference between the systolic and diastolic pressure.

Increased pulse pressure ( ≥60 mm Hg):

anemia, exercise, hyperthyroidism, arteriovenous fistula,

aortic regurgitation, increased intracranial pressure, and

patent ductus arteriosus.

Narrowed pulse pressure (≤20 mm Hg) :

hypovolemia, increased peripheral vascular resistance as

seen in early septic shock, or decreased stroke volume.


Interpretation

4 Differential Brachial Artery Pressures:

The normal value of systolic blood pressure

differences between arms is .

> mmHg may indicate:

advanced focal atherosclerosis, aortic dissection, other aortic arch syndromes, et al.

10-20mmHg

20


Interpretation

5 Mean arterial blood pressure (MAP): MAP is considered to be the perfusion pressure seen by organs in

the body.

MAP Formula:

MAP > 60 mmHg is enough to sustain the organs of the average person. If the MAP falls significantly below this number for an appreciable time, t

he end organ will not get enough blood flow, and will become ischemic.


5 PULSE OXIMETRYPULSE OXIMETRY

SpO2

The pulse oximeter provides a

rapid, noninvasive, and continuous

measurement of arterial oxygen

saturation that has become a

uniform standard for patient

monitoring throughout medicine.


Indications

patients with acute cardiopulmonary disorders

such as bronchiolitis, asthma, heart failure, and

COPD.

patients with drug-induced or traumatic

alterations in consciousness.

patients undergoing procedural or deep sedation

patients requiring definitive airway management.


6 ELECTROCARDIOGRAPHY

ECG

Continuous ECG permits:

1.detection of arrhythmias

2.evaluation of pacemaker function

3.detection of myocardial ischemia

4.detection of electrolyte abnormalities


Indications

patients with potential for developing arrhythmias.

patients at risk of hemorrhage or those undergoing fluid resuscitation

patients at risk of myocardial ischemia (ST segments)

detect certain electrolyte abnormalities

all ICU patients (The American Heart Association recommend class I intervention).

particularly those with acute myocardial infarction, traumatic cardiac contusion, following cardiac surgical procedures, and those with a prior history of arrhythmia

such as hypokalemia during treatment of

diabetic ketoacidosis.


Correct electrode placement

Locations of the unipolar precordial leads on the body surface.

Section Two Emergency Procedures



1 Upper Extremity Venipuncture

Venipuncture is performed to obtain a sample of venous blood for laboratory testing.

Technique of percutaneous venipuncture. The needle should be inserted into the lumen of the vein at an angle of about 10–20 degrees, and the bevel should be facing up.


2 Peripheral Venous Catheterization with a Catheter-Clad Needle

Catheter-clad needles are generally preferred for peripheral intravenous access because they provide the largest-diameter catheter lumen possible for a given size of venipuncture.

Their flexibility gives them an advantage over rigid needles for long-term use.

A: Technique of removing the needle from the catheter-

clad needle. B: Connecting the intravenous tubing.C: Technique of securing an intravenous

catheter to the skin with tape after insertion.

C


3 Internal Jugular Vein Catheterization

Internal jugular vein catheterization is performed to gain access to the central venous system for administration of fluids and measurement of central venous pressure.

Pulmonary complications (hemothorax, pneumothorax) occur less commonly than with subclavian vein catheterization, but arterial injury (e.g., to the carotid artery) is more common.

middle approach posterior approach


4 Subclavian Vein Catheterization

Subclavian vein catheterization is performed to gain venous access for monitoring of central venous pressure, insertion of a transvenous pacemaker, or administration of medications or intravenous fluids.

Technique of subclavian vein catheterization. With the index finger in the suprasternal notch and the thumb

marking the costoclavicular ligament, insert the needle just medial to the thumb.

Anatomic relationships of the subclavian vein.


5 Femoral Vein Phlebotomy or Catheterization

Femoral vein catheterization is

an easy way to gain rapid access

to the central venous system (for

example, during CPR).

Femoral vein phlebotomy is

useful in patients in whom

peripheral veins of the

extremities are not palpable

(e.g., intravenous drug abusers).

Because infection is common at

this site, the femoral vein should

not be used for procedures

requiring long-term venous

access and blood culture.

Anatomic relationships of the femoral vein at the inguinal ligament.


6 Radial Artery Puncture: For Blood Gas & PH Analysis

Indications :

Need to obtain arterial blood for blood gas and pH determinations.

Need to perform phlebotomy when other sites are inaccessible.Technique of radial artery puncture. The

index and middle fingers are used to identify the point of maximum pulsation.


7 Direct Laryngoscopy and Orotracheal Intubation

Indications:

1. Inadequate oxygenation (e.g., decreased arterial PO2) that is not corrected by supplemental oxygen supplied by mask or nasal cannula.

2. Inadequate ventilation (increased arterial PCO2).

3. Need to control and remove pulmonary secretions (bronchial toilet).

4. Need to provide airway protection in an obtunded patient or a patient with a depressed gag reflex.

5. Need to perform urgent or emergency diagnostic studies in a multiple injured or intoxicated patient or in an uncooperative patient with head injury.

Technique of direct laryngoscopy and orotracheal intubation.


8 Nasogastric Intubation: for Gastric Evacuation or Lavage

Indications:1. Need to suppress vomiting caused by gastric

distention or paralytic ileus.2. Need to perform gastric lavage (therapeutic or

diagnostic).3. Need to perform gastric decompression.4. Need to perform gastric evacuation.

Technique of nasogastric intubation.


9 Insertion of Sengstaken–Blakemore Tube

Has triple-lumen rubber tube with two balloons:

one is inflated in the lumen of the stomach and pressed against the esophagogastric junction;

one is inflated in the lumen of the esophagus to press directly against the varices.

the third opens into a port on the distal tip of the tube and is used to irrigate and drain the stomach.

Sengstaken–Blakemore Tube


9 Insertion of Sengstaken–Blakemore Tube

Indications: Need to control massive

upper gastrointestinal tract hemorrhage presumed to result from esophageal varices in a patient with hypovolemic shock.

Need to control documented esophagovariceal hemorrhage in a patient with or without hemodynamic compromise.

Balloon tamponade for bleeding varices. The Sengstaken–Blakemore tube has a

small gastric balloon (arrow) that can be inflated to 250 mL with air.


10 Cricothyrotomy

Cricothyrotomy is performed when the airway must be secured or maintained and when attempts at orotracheal or nasotracheal intubation have failed.

Transections or fracture of the trachea, larynx, or cricoid cartilage are contraindications.

Anatomic relationships of cricothyroid membrane. Incision Site of cricothyrotomy.


11 Thoracentesis

Indications: To relieve dyspnea

or respiratory distress caused by accumulation of fluid in the pleural space.

To obtain pleural fluid for diagnostic tests.

Technique of thoracentesis using a regular steel needle.

A: Successful tap, with fluid obtained.

B: Air is obtained if the position of the needle tip is too high (lung is punctured, or preexisting pneumothorax is entered, as in illustration).

C: A bloody tap may result from excessively low position of the needle with puncture of the liver.


12 Pericardiocentesis

Blind pericardiocentesis should be utilized for those situations in which a critically ill patient is suspected of having tamponade and no diagnostic tests are rapidly available to assist in the diagnosis or treatment (e.g., bedside ultrasound).

Diagram of pericardiocentesis showing position of needle and anatomic relationships.


13 Focused Assessment with Sonography for Trauma (FAST)

FAST is a rapid, noninvasive technique for determining the presence of intra-abdominal fluid (e.g., blood or urine) in the trauma victim.

Indications: Blunt thoracoabdominal trauma. Penetrating thoracoabdominal

trauma. Suspected pericardial

tamponade. Undetermined origin of

hypotension in trauma patient.

It does not detect retroperitoneal fluid collections or hollow viscus injury such as bowel perforation.

A, atrium; B, bladder; F, fluid; K, kidney; L, liver; S, spleen; V, ventricle.

1 2

34


14 Abdominal Paracentesis

Indications:

1. To determine the cause of ascites, including suspected intra-abdominal hemorrhage from trauma.

2. To lower intra-abdominal pressure in tense ascites (rarely indicated in the emergency department).

3. To obtain fluid for analysis and culture in patients with ascites who are thought to have an infection.

Insertion site for abdominal paracentesis.


15 Insertion of Indwelling (Foley) Urinary Catheter

Indications:

1. Diagnostic or therapeutic drainage of the urinary bladder.

2. Need for a reliable and frequent assessment of urine output (e.g., for treatment of shock).

3. Need to perform retrograde cystography.

Sagittal section of female bladder showing balloon of Foley catheter fitting snugly against the trigone.


16 Lumbar Puncture

Lumbar puncture is performed to obtain cerebrospinal fluid for diagnostic tests (e.g., suspected meningitis, subarachnoid hemorrhage).

Decubitus position for lumbar puncture.

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Chapter Two Monitoring Techniques and Procedures of Emergency Medicine Jia Xu The First Affiliated Hospital of College of Medicine, Zhejiang University