RAPID Approach to Managing Patients in the Emergency Department



Rob Woods MD FRCPC
Created September 10th, 2009

from Microsoft Clip OrganizerMaking the transition to clerkship training can be challenging. You will have been taught your basic history and physical examination skills, and you will have been taught a great deal about diseases and their treatments. The art of putting this all together takes lots of practice. Adding to this are some unique aspects of caring for patients in the Emergency Department (ED).

  • ED patients may require resuscitation. At your stage you are not necessarily expected to independently manage a patient in extremis, however we do you want you to start thinking about how you recognize these patients and have a basic differential diagnosis and initial management plan for altered mental status, airway obstruction, shortness of breath and shock. It is not enough just to repeat the mantra ‘ABC’s’ anymore. You have to be more specific and detailed about this area of patient care. An important skill all physicians should have is to tell when a patient is ‘sick’.
  • In addition to resuscitation, patients often present to the ED because they are pain. There is ample literature that practicing Emergency Physicians do not do an adequate job of providing timely and effective analgesia or antiemesis. Hopefully by making this explicit to you, you will make this a regular part of assessing your patients.
  • Patients also have underlying psychosocial stressors precipitating or contributing to their ED visit. It is important that you are aware to search for these stressors so that patients will be satisfied with their visit and that both their medical and non-medical needs are met.
  • Finally, the majority of patients seen in the ED are sent home. Not all of these patients will have their complaint completely diagnosed and treated. Undiagnosed symptoms are often discharged from the ED and you will not likely see them in follow-up yourself. You need to develop skills in determining which patients need admission and which ones need specific follow-up and testing. You also need to learn about the out-patient resources that exist so you can ensure follow-up for your patients and ‘close the loop’ on any outstanding issues you were unable to address during their time with you.
This is a tall task for any physician, particularly if you are just starting your clerkship. A mnemonic has been developed to assist you, so that you have a memory aid when assessing your patients in the ED:

R
Resuscitation
A
Analgesia & Assessment (History & Physical Exam)
P
Patient needs (Non-medical)
I
Interventions (Diagnostic & Therapeutic)
D
Disposition



Resuscitation

The first thing you should look at with every patient you see are the vital signs and chief complaint. ALL ABNORMAL VITAL SIGNS MUST BE EXPLAINED. Sometimes slight tachycardia that resolves is only a result of the flight of stairs the patient climbed on their way to the triage desk. Other times it may clue you in to a potential serious pathology. For example: BP 90/70 in a 23 y o female with abdominal pain could be a ruptured ectopic pregnancy, RR of 35 in an elderly lady with confusion could be an ASA overdose, in a dehydrated 12 y o it could mean they have DKA, Temp of 35.4 in a newborn is most likely sepsis. It is important for you to be familiar with normal ranges of vital signs so you can recognize when they are abnormal, allowing you to heighten your suspicion for serious pathology.

The next step is to have a quick look at the patient. If on quick inspection the patient appears to be in distress (particularly if they have abnormal vital signs), or the nurses look concerned, you need to delay your history and assess the patients’ ABC’s:

Airway - starts with seeing if the patient can speak to you. Absence of stridor, secretions and snoring rule out immediate airway obstruction.

Breathing - respiratory rate, work of breathing, O2 sats, lung sounds, symmetry of chest movement will help you determine if the patient is in respiratory distress or failure. RR is often inaccurate because nurses and physicians determine it by looking at the patient for only 5-10 seconds. Take it over 30-60 seconds to ensure it is accurate as it is a very sensitive indicator of pathology.

Circulation - heart rate, blood pressure, color, peripheral perfusion and pulses will help you determine if you patient is in shock.

Disability – altered mental status can be objectively determined by the Glascow Coma Scale. Any patient with altered mental status needs a stat blood sugar to see if they are hypoglycemic or in DKA (diabetic keto-acidosis).

If the patient is ‘sick’ and you are assessing ABC’s, you still need to take a history, but it may need to be taken in stages. SAMPLE is a good way to take a quick relevant INITIAL history in a patient who is unwell.

Symptoms or chief complaint
A
llergies
M
edications
P
ast Medical History
L
ast Meal
E
vents leading up to the presentation (brief HPI) can often give you enough information to develop an initial differential diagnosis to start your investigations/treatments.

Analgesia & Assessment


Patients often present to the ED with pain and/or nausea. Prompt administration of pain relief and anti-nauseants will not only make your patients more comfortable, but it will also improve your assessments of them. Some commonly used medications for pain and nausea in the ED are:

IV Normal Saline 1-2L bolus

Acetaminophen (Tylenol) 325-975mg PO Q4H
Ibuprofen (Advil) 200-800mg PO Q6H
Hydromorphone (Dilaudid) 1-4mg PO PRN

Nitroglycerine 0.3mg spray PRN
‘Pink Lady’ (Dioval & Viscous Lidocaine)
Pantoprazole (Pantoloc) 40mg IV Q12H
Ativan 1-2mg PO/SL/IV PRN

Morphine 1-10mg IV PRN
Ketorolac (Toradol) 30-60mg IV Q6H
Fentanyl 25-100mg IV PRN

DimenhyDRINATE (Gravol) 25-50mg PO/IV Q4H
Maxeran 10mg PO/IV Q6H
Ondansetron (Zofran) 2-4mg PO/IV Q6H


Assessment and treatment of pain should be done in parallel with your assessment. You do not need to complete your assessment before you order analgesia. You can always interrupt your assessment to find a nurse and ask them to start an IV and/or give pain medications and then continue your assessment. For more minor concerns such as limb pain and suspected fractures, make sure your patient receives analgesia BEFORE they go to xray. This way the medication will have had a chance to take effect by the time you go to re-assess them after viewing the xray.

In the ED, patients do not always bring themselves in. Often they are brought by ambulance without any family or friends with them. In situations where the patient cannot provide an adequate history, it is important that you take the initiative to talk to the paramedics who brought the patient in. Find out where they live and what the circumstances were that brought them in (ie who called the ambulance). Track down phone numbers for family and friends and call them to get collateral history. Get old charts from your hospital or any hospital where they were recently seen. It is not acceptable to just state that the patient is a ‘difficult historian’.

Once you have completed your assessment, you need to generate a Differential Diagnosis. Your skills at this will only improve if you commit to a list of potential causes so your preceptor can help you develop your clinical reasoning.

Patient Needs

Trying to determine underlying motivations or stressors for an ED visit can be challenging, and you will not always be successful, but it is important that you try. Domestic violence and sexual assault are common contributors for women to seek help in an ED. If your patients are willing to disclose this information to you, you can put them in touch with services that will help them deal with their non-medical needs.

Other times, patients with adequate supports at home come to the ED unexpectedly. Their family does not know they are there and they may have work or child-care commitments that they need to make contingency plans for. Once you are finished your assessment, it is always useful to ask if they need to call anyone to let them know they are there.

Even when patients arrive with a family member, they do not know if they will be admitted or discharged, and if they are discharged, how long they will have to stay. Once you know your diagnostic and treatment plan for your patient, it is important to communicate that plan to your patient so they can make arrangements. Husbands and wives do not need to stay at 11:00pm when you know that you will be keeping their spouse overnight for observation. Send their family member home (ensuring you have accurate contact information).

Think about disposition at this point. Will there be any barriers to sending your patient home if your tests are all normal? (see Disposition below)

Interventions

Interventions are both diagnostic and therapeutic. Once you have determined your differential diagnosis, think about what tests you would like to order for your patient. If you have not already provided analgesia for your patient, do so if indicated. If you have a clear diagnosis on initial assessment (ie new onset Atrial Fibrillation), your specific therapy can begin immediately. Otherwise it may need to wait until you have the results of your investigations (ie. consolidation on a CXR prior to initiating antibiotics). Much like your clinical reasoning, it is important for you to commit to a diagnostic and treatment plan so your preceptor can help you develop these skills.

Once you know your plan, make sure the patients, families and nurses are aware. Nurses can then notify you when test results are available or if your patient requires further treatments.

Disposition

After determining a management plan for your patient, you need to ask yourself, what do I do if all of my tests are normal? GI bleed with a hemoglobin of 70 is an easy disposition…admit. When the hemoglobin is 110, it is not so clear. Will your patient be able to follow-up if they have worsening symptoms? Do they have access to transportation? Do they have a phone? Many social issues play into disposition; make sure you assess these issues during your first contact with the patient so you can address them early in the patient encounter.

If you do ask for a consultant to see your patient it is important to communicate your consultation effectively and efficiently. They do not want to hear a history and physical. They want to hear who you are and why you are calling in less that 30 seconds. State your name, the demographics of the patient, the most likely diagnosis or symptom complex and suspected diagnosis, the stability and comfort level of the patient, and what you would like them to do. An example:

‘Hi Dr X, this is Y, one of the JURSI’s working in the Emergency Department. I have Mr Z, an 80 yr old man with a lower GI bleed. His blood pressure is 135/70 and has been stable. His Hb is 85 with no further episodes of bleeding. I was hoping your team could assess him for an admission and further work-up.’

At this point the consultant may want to know more specifics, so have your chart and labs ready to answer.

If you do end up sending your patient home with or without specific follow-up, you need to make sure they understand the treatment plan. Explain any prescriptions to them. The pharmacy will do this as well, but it never hurts to hear it twice. If a family member is with the patient, explain things to them as well. Two people are more likely to remember all of the details of the care plan. If you arrange a follow-up appointment or diagnostic test, make sure the patient’s phone number is correct and that a contingency plan is in place if they do not get contacted in an appropriate amount of time.

The ED is also an area where preventative health measures can be implemented. Promoting bike helmets and car seats take very little time but can be life-saving. Warning parents of toddlers about the hazards of stairs and choking can also be life-saving. Having a physician tell a patient to stop smoking may be enough for them to do so. Ensuring your patients wear an ankle brace for 6 months after a sprain may keep them from re-injuring their ankle. Ensuring any patient who has had a seizure is aware to avoid situations where a subsequent seizure could result in injury is also important. Almost every patient has some area of health promotion that could be addressed during their ED visit.
Here are some examples of ED cases to practice the RAPID approach:


Case 1

A 23 y o female presents to the ED with abdominal pain. She is by herself. Her vital signs are as follows: HR 86, BP 115/72, RR 14, O2 99% RA, T 37.1. On quick assessment she appears in mild to no distress.

Any concerns for Resuscitation? Is there any potential serious pathology?


She describes a mild suprapubic tenderness. It got worse this evening so she came to the ED. It began 3 days ago. 2 days ago she noticed a mild whitish vaginal discharge, which has been persistent since. She denies dysuria. No change in appetite. No vomiting or change in bowel routine. Prior to 3 days ago she did not have these symptoms. Her LMP was 3 weeks ago and was typical for her. She has no previous medical problems and has never been pregnant. She has had one sexual partner in the past 3 months, her last sexual encounter was one week ago.

On exam, her CVS, Resp and H&N exams are normal. She has mild suprapubic tenderness. On pelvic exam she has whitish cervical discharge and cervical motion tenderness. There is no adnexal mass or tenderness.

How will you treat her pain? What is your differential diagnosis?

What are your patient’s non-medical needs?

What is your diagnostic and treatment plan?

What is your disposition for this patient?


Case 2

A 55 y o male presents to the ED with chest heaviness and diaphoresis. He is by himself. His vital signs are as follows: HR 72, BP 148/86, RR 19, O2 95% RA, T 36.8. On quick assessment he appears to be in moderate to severe discomfort.

Any concerns for Resuscitation? Is there any potential serious pathology?

Do you want to address Analgesia now or after your assessment?

He describes a central chest heaviness that began 1 hour ago while in his office at work. It became quite severe over the next 10 minutes so he called an ambulance and was brought to the ED. He has associated diaphoresis and shortness of breath. He has been having milder versions of this pain during exercise over the past couple months, but this is the first episode at rest. He is a 30 pack year smoker and takes Ramipril for hypertension. He has no other health problems.

On examination he is diaphoretic and uncomfortable. His CVS, Resp and Abdominal examinations are normal.

What is your differential diagnosis?

What are the patient’s non-medical needs?

What is your diagnostic and treatment plan?

What is your disposition for this patient?


Case 3

An 80 y o female is presents to the ED with dizziness. She was brought by her daughter. Her vital signs are as follows: HR 65, BP 166/84, RR 15, O2 94% RA, T 36.3. She does not appear to be in significant distress.

Any concerns for Resuscitation? Is there any potential serious pathology?

Do you want to address Analgesia now or after your assessment?

She describes a sensation that the room is spinning around her. It began 4 hours ago and she described it as sudden in onset. It has not changed in character or intensity since it began. She has some associated headache and nausea, but has not vomited. She describes some mild visual changes (blurriness). She has not had previous similar symptoms. She had a fall from standing height 4 days ago, but did not complain of any symptoms at that time. Otherwise she has been feeling well recently. Her past history is significant for Atrial Fibrillation (Coumadin, Metroprolol).

On examination her visual acuity is 20/40 corrected in both eyes. Her H&N exam reveals not carotid or vertebral bruits. Her heart sounds are irregular, and there are no murmurs. Her Resp and Abdo examinations are normal. Her neurological examination is normal (cranial nerves, motor and sensory) except for mild ataxia and a positive Romberg.

What is your differential diagnosis?

What are the patient’s non-medical needs?

What is your diagnostic and treatment plan?

What is your disposition for this patient?


Case 4

A 66 y o male presents to the ED with back/flank pain. He is by himself. His vital signs are as follows: HR 105, BP 125/88, RR 22, O2 sat 96% RA, T 37.3. He is in moderate to severe discomfort and does not want to lie still on the stretcher.

Any concerns for Resuscitation? Is there any potential serious pathology?

Do you want to address Analgesia now or after your assessment?

He describes a pain that came on suddenly while watching TV. It is located in the right side of his back and radiates to his groin. It is the most severe pain he has ever felt and he ranks it as a 10/10. He denies urinary symptoms or change in bowels. He feels nauseated and has vomited once prior to arrival. His past history is significant for Hypertension (HCTZ).

On examination he has mild mid-abdominal tenderness without guarding or rebound. His bowel sounds are present. He has Right flank tenderness. His CVS, Resp and H&N exams are normal.

What is your differential diagnosis?

What are the patient’s non-medical needs?

What is your diagnostic and treatment plan?

What is your disposition for this patient?


Case 5

A 54 y o female presents to the ED with Shortness of Breath. She is brought by ambulance. Her vital signs are: HR 122, BP 133/74, RR 28, O2 88% RA, T 37.8. She appears to be working quite hard to breath and is speaking in 3 word sentences.

Any concerns for Resuscitation? Is there any potential serious pathology?

Do you want to address Analgesia now or after your assessment?

She tells you that she has been feeling SOB for the past few days but it got much worse this morning. She has been coughing more than usual and her phlegm has turned green in color. She is known to have Bronchitis, but ran out of her puffers. She has a 40 pack year history of smoking. Apart from her puffers she is on no medication.

On examination, she is tachypneic and using her accessory muscles of respiration. She has diffuse wheezes bilaterally and some fine crackles at the right lung base. Her CVS exam is normal expect for tachycardia, and her abdominal examination is normal.

What is your differential diagnosis?

What are the patient’s non-medical needs?

What is your diagnostic and treatment plan?

What is your disposition for this patient?

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