Managing Emergencies In Mass Participation Events: Medical Triage and Algorithms

Transcription

1 Managing Emergencies In Mass Participation Events: Medical Triage and Algorithms 2010 Marine Corps Marathon Symposium Francis G. O Connor, MD, MPH Medical Director, Consortium for Health And Military Performance (CHAMP) Associate Professor of Military and Emergency Medicine Uniformed Services University of the Health Sciences Scott Pyne, MD Former Medical Director, Marine Corps Marathon Consultant, Sports Medicine US avy Medical Department W. Bruce Adams, MD Medical Director, Marine Corps Marathon Senior Medical Officer USMC Reserve Medical Entitlements Determinations Wounded Warrior Regiment Quantico, VA Fred H. Brennan, Jr., DO Director, Seacoast Center for Athletes Team Physician, University of ew Hampshire Somersworth, H Thomas Howard, MD Director, Sports Medicine Fellowship Program Fairfax Family Practice Fairfax, VA Chris G. Pappas, MD FAAFP Director, Primary Care Sports Medicine Womack Family Medicine Residency Program Fort Bragg, C

2 2 Table of Contents I. MCM Collapsed Athlete Algorithm 3 II. MCM Emergency Cardiac Care Algorithm 4 III. MCM Exercise Associated Collapse Algorithm 5 IV. MCM Hyperthermia Algorithm 6 V. MCM Hypothermia Algorithm 7 VI. MCM Exercise Associated Muscle Cramps Algorithm 8 VII. MCM Chest Pain Algorithm 9 VIII. MCM Hyponatremia Algorithm 10 IX. MCM Hypoglycemia Algorithm 11

3 3 MCM COLLAPSED ATHLETE ALGORITHM ATHLETE COLLAPSES DURIG OR AFTER EVET ASSESS RESPOSIVEESS EXIT TO EMERGEC CARDIAC CARE ALGORITHM O SHOCK/CPR IDICATED RETUR TO ALGORITHM SHOCK/CPR IDICATED BRIEF HISTOR AD PHSICAL VITAL SIGS + RECTAL TEMP COSIDER: i-stat a+, Glucose ASSESS VS (RECTAL TEMP) CV & RESP SUPPORT AS EEDED TRASPORT TO ER ALTHETE WITH IDETIFIABLE MEDICAL CODITIO IITIATE IMMEDIATE AD APPROPRIATE ACTIO COSIDER: HPOGLCEMIA, HPOATREMIA, CRAMPIG, CHEST PAI PROTOCOLS RECTAL TEMP >104 o F//40 o C EXIT TO HPERTHERMIA ALGORITHM RECTAL TEMP 97 o F//36 o C TO 104 o F// 40 o C RECTAL TEMP <97 o F//36 o C EXIT TO EXERCISE-ASSOCIATED COLLAPSE ALGORITHM EXIT TO HPOTHERMIA ALGORITHM

4 4 II. MCM EMERGEC CARDIAC CARE ALGORITHM (BLS SETTIG WITH AED) PERSO COLLAPSES POSSIBLE CARDIAC ARREST ASSESS RESPOSIVEESS URESPOSIVE COTIUOUS CCLES OF CPR AD RHTHM ASSESSMET UTIL RETUR OF PULSE AD RESPIRATIOS OR RELIEVED B EMS SHOCKABLE RHTHM ACTIVATE EMS CALL FOR DEFIBRILLATOR OR AED PRIMAR SURVE (ABCD) A OPE AIRWA B ASSESS BREATHIG OT BREATHIG B--GIVE TWO SLOW BREATHS C--ASSESS PULSE O PULSE C--START CHEST COMPRESSIOS WITH VETILATIO D--ATTACH AED (DEFIBRILLATOR) ASSESS RHTHM PULSE O-SHOCKABLE RHTHM RESCUE BREATHIG* CHECK PULSE Q 2 MIUTES TRASPORT TO ER (VF/VT) SHOCK OCE O-VF/VT ASSTOLE OR PEA RESUME CPR FOR 5 CCLES (< 2 MIUTES) RESTORATIO OF RHTHM AD BP RESUME CPR FOR 5 CCLES (< 2 MIUTES) ASSESS VS (RECTAL TEMP) CV & RESPIRATOR SUPPORT AS EEDED TRASPORT TO ER *ADULT RESCUE BREATHIG RATE: 1 BREATH EVER 5-6 SECODS ADULT CPR: 30 COMPRESSIOS PER 2 VETILATIOS COMPRESSIO RATE = 100/MIUTE COMPRESSIO DEPTH = 2" WITH FULL CHEST RECOIL (2005 American Heart Association Guidelines)

5 5 III. MCM EXERCISE-ASSOCIATED COLLAPSE ALGORITHM PATIET WITH PROBABLE EXERCISE-ASSOCIATED COLLAPSE OBVIOUS SIGS OF DEHDRATIO MARKED MS CHAGES ORAL REHDRATIO SUPIE WITH LEGS ELEVATED ICHES ABOVE THE HEART REASSESS I MIUTES: - SUPIE HR, BP - RECTAL TEMP - METAL STATUS T > 102 º F//39 º C SBP < 110 HR > 100 MS CHAGES COSIDER IV ACCESS + 1 LITER D5S SUPIE WITH LEGS ELEVATED ICHES ABOVE THE HEART IV ACCESS, COSIDER 1 LITER S AS IDICATED LABS: SODIUM, GLUCOSE TREAT/TRIAGE A IDETIFIED SODIUM/GLUCOSE ABORMALITIES COSIDER ER TRASFER IITIATE IMMEDIATE COOLIG MEASURES AS APPROPRIATE COSIDER 1 MORE LITER S IF SERUM SODIUM IS ORMAL IF AVAILABLE, COSIDER ODASETRO 4MG IV OR 8 MG ODT FOR PERSISTET AUSEA/VOMITTIG REASSESS I MIUTES: - SUPIE HR, BP - RECTAL TEMP - METAL STATUS T > 102 º F//39 º C SBP < 110 HR > 100 MS CHAGES OBSERVE AD MAAGE AS APPROPRIATE COSIDER ER TRASFER FOR FAILURE TO MEET CRITERIA FOR SUPIE WITH LEGS ELEVATED ICHES ABOVE THE HEART CRITERIA FOR DISCHARGE: LABS: SODIUM, GLUCOSE IITIATE IMMEDIATE COOLIG MEASURES AS APPROPRIATE PT ABLE TO AMBULATE O OW POWER ORMAL METAL STATUS

6 6 IV. MCM HPERTHERMIA ALGORITHM RECTAL TEMP > 104 º F//40 º C LOSS OF THERMOREGULATOR COTROL EVIDECE OF ACUTE ORGA DSFUCTIO RAPID EXTERAL COOLIG IV S 1-2 LITERS (OBTAI BLOOD CHEMISTR SAMPLES ) CORE TEMPERATURE MOITORIG (Q 3 MI RECTAL TEMPERATURE OR IDWELLIG RECTAL THERMISTOR COTIUOUS VITAL SIG REASSESSMET COTIUOUS COOLIG ITERVETIOS T < 102 º F//39 º C STOP COOLIG TREATMET MOITOR FOR TEMPERATURE REBOUD OR HPOTHERMIC OVERSHOOT PERSISTET METAL OBTUDATIO o SEVERE RHABDOMOLSIS EVIDET EED FOR OGOIG IV HDRATIO ASSESS FOR HPOGLCEMIA, HPOATREMIA OR OTHER ETIOLOG FOR CS ALTERATIO & TREAT ACCORDIGL TRASPORT TO ER RELEASE WITH EXERCISE RESTRICTIOS & PRECAUTIOS REGARDIG RHABDOMOLSIS ALL TEMPERATURES ARE RECTAL! RAPID COOLIG OPTIOS: ICE BATH IMMERSIO, WHOLE BOD ICE MASSAGE, COTIUOUS DOUSIG WITH ICE WATER &/OR ICE WATER-SOAKED SHEETS. FAS IF AVAILABLE. COSIDER COOLED IV FLUIDS. STOP COOLIG WHE TEMPERATURE DROPS BELOW IVF: S 2L BOLUS ULESS SIGS OF OVER-HDRATIO OR CHF (THE KVO RATE); REASSESS O-GOIG IVF EEDS FROM CLIICAL RESPOSE, URIE OUTPUT, AD LABS. COOLED FLUIDS FOR HEAT CASUALT. IMMEDIATE a, Gluc, K +/- Cr, BU, Cl & Hct (e.g. i-stat ); TREAT HPOGLCEMIA AD HPOATREMIA PER PROTOCOLS. IF RHABDOMOLSIS SUSPECTED, EED CPK, BMP, AST, ALT, LDH, Uric Acid & UA w/ Micro IF AVAILABLE.

7 7 V. MCM HPOTHERMIA ALGORITHM PATIET PRESETS WITH SUSPECTED COLD IJUR IITIAL THERAP FOR ALL PATIETS: 1. REMOVE WET CLOTHIG 2. PREVET FURTHER HEAT LOSS (BLAKETS, MOVE TO WARMER EVIROMET) 3. OBTAI CORE TEMPERATURE 4. AVOID ROUGH MOVEMETS/PATIET HADLIG 5. ASSESS CARDIAC RHTHM PRIMAR SURVE (ABC s) CHECK PULSE PULSE PRESET O PULSE WHAT IS THE CORE TEMPERATURE? 95 F//35 C TO 97 F//36 C SIGIFICAT HPOTHERMIA EFFECTS? 86 F//30 C TO 93 F//34 C IITIATE PASSIVE EXTERAL REWARMIG COSIDER WARM FLUIDS** +/- WARMED IV S <86 F//30 C IITIATE PASSIVE EXTERAL REWARMIG AD WARMED FLUIDS ** OR WARMED IV S DEFIBRILLATE SECURE AIRWA VETILATE WITH WARMED OXGE ESTABLISH IV ACCESS IFUSE WARMED S PASSIVE EXTERAL REWARMIG DISCHARGE WHE IDICATED REASSESS I MIUTE: IMPROVED? TRASPOR T TO EMERGEC ROOM *THIS ALGORITHM IS ITEDED FOR THE FIELD MAAGEMET OF COLD IJURIES I THE SETTIG OF MASS PARTICIAPTIO EVETS ** IF OBTUDED, O ORAL FLUIDS.

8 8 VI. MCM EXERCISE-ASSOCIATED MUSCLE CRAMPS ALGORITHM IITIAL TREATMET PROTOCOL VITAL SIGS/REST O COT COSIDER i-stat SERUM SODIUM 1 GETLE MASSAGE/PASSIVE STRETCHIG/ICIG/ APPROPRIATE COOLIG/ORAL REHDRATIO 2 ADMIISTER ORAL SALT 3 / HIGH SODIUM FOOD OBSERVATIO FOR 20 MIUTES CRAMPS RESOLVED? SECODAR TREATMET PROTOCOL CHECK i-stat SERUM SODIUM START IV: BOLUS 1-2 LITERS ORMAL SALIE MOITOR VITAL SIGS; IF VITALS OT STABILIZIG OR CRAMPS OT RESPODIG COSIDER TRASPORT IF AVAILABLE, COSIDER MGSO4 2-3 GMS ADDED TO 1 LITER IV BAG DISCHARGE AS APPROPRIATE 1. A i-stat SERUM SODIUM SHOULD BE COSIDERED FOR PATIETS WITH SEVERE SSTEMIC CRAMPIG, OR CRAMPIG ASSOCIATED WITH EUROLOGIC COMPLAITS SUCH AS PERSISTET UMBESS OR TIGLIG. THESE SMPTOMS MA BE CLUES TO HPOATREMIA. 2. ORAL REHDRATIO FLUID SHOULD BE A FLUID OF CHOICE; HOWEVER, A ELECTROLTE SOLUTIO SUCH AS GATORADE, OR A SALT BROTH, SHOULD BE ECOURAGED. 3. ORAL SALT IGESTIO IF O COTRAIDICATIOS. MA EMPT SMALL PACKET OR ½ TSP SALT O TOGUE THE CHASE WITH WATER/SPORTS DRIK (REPEAT PR). TR SALTED CHIPS, PRETZELS, CRACKERS. MA TR ELECTROLTE TABS (OFTE HAVE LOW SODIUM COTET)

9 9 VII. MCM CHEST PAI ALGORITHM CHEST PAI: SUGGESTIVE OF ISCHEMIA IMMEDIATE ASSESSMET: VITAL SIGS OXGE SATURATIO IV ACCESS 12 LEAD ECG IMMEDIATE TREATMET: OXGE ASPIRI ITROGLCERI HELP! ACTIVATE EMS! IMMEDIATE GEERAL TREATMET ACTIVATE EMS OXGE: 4L/MI B MASK OR CAULA ASPIRI: 325 MG TABLET SHOULD BE ADMIISTERED (CHEWED) ITROGLCERI: OE SUBLIGUAL TABLET (0.03 TO 0.04 MG) SHOULD BE ADMIISTERED AD MA BE REPEATED TWICE AT 5 MIUTE ITERVALS. SSTOLIC BP SHOULD BE GREATER THA MM HG.

10 10 VIII. MCM HPOATREMIA ALGORITHM HPOATREMIA SUSPECTED: ORMOTHERMIC; FEELS AD LOOKS BAD; +/- METAL STATUS CHAGES; PERSISTET CRAMPIG OR /V; WEIGHT GAI; SWELLIG. MARKED METAL STATUS CHAGES, COMA, OR SEIZURES? ORMAL METAL STATUS OR OL MILD COFUSIO CHECK BASELIE i-stat SODIUM BROTH, SALTED CRACKERS COSIDER IV S KVO REPEAT i-stat I 30 MIUTES CLIICALL WET: HX LARGE FLUID ITAKE EE MUCOSA WET O ORTHOSTASIS WEIGHT ICREASED i-stat SODIUM LEVEL SODIUM < 125 CLIICALL DR: HX HEAV SWEATIG & POOR FLUID ITAKE EE MUCOSA DR ORTHOSTATIC WEIGHT DECREASED SODIUM > 125 COSIDER HPOATREMIA BUT CAREFULL ASSESS FOR OTHER POTETIAL CAUSES OF SMPTOMS AD TREAT ACCORDIGL SODIUM > 125 SMPTOMS RESOLVED 3% SALIE 1CC/KG OR 100 CC OVER MI 3% SALIE 1CC/KG OR 100 CC OVER MI OR S 1-2 LITER BOLUS IF CERTAI O FLUID OVERLOAD REASSESS & TREAT ACCORDIGL; DISCHARGE OR TRASPORT TO ER AS APPROPRIATE SODIUM > SMPTOMS RESOLVED COSIDER REPEAT DOSIG OF 3% SALIE SODIUM > SMPTOMS RESOLVED DISCHARGE DISCHARGE STABILIZE & TRASPORT TO ER

11 11 IX. MCM HPOGLCEMIA ALGORITHM SIGS/SMPTOMS OF HPOGLCEMIA AD/OR KOW DIABETIC VITAL SIGS + FIGER STICK (FS) GLUCOSE FS>55mg/dl FS<55mg/dl ASSESS RESPOSIVEESS Responsiveness EVALUATE AD TREAT AS IDICATED COSCIOUS AD ORIETED BRIEF H&P VITAL SIGS +/- IV ACCESS MOITOR ORAL GLUCOSE gm OBSERVE 10 TO 15 MIUTES FS >55 mg/dl AD ASMPTOMATIC ALTERED METAL STATUS WITHOUT SEIZURE BRIEF H&P PROTECT ABC s OXGE IV ACCESS MOITOR 1 AMP (25gm) D50W START D5S RECHECK FSG I 15 MIUTES UCOSCIOUS +/- SEIZURE BRIEF H&P PROTECT ABC s OXGE IV ACCESS MOITOR GLUCAGO 1mg SC/IM START D5S or D10W TRASPORT TO ER REPEAT ORAL GLUCOSE CHALLEGE OBSERVE 10 TO 15 MIUTES FS > 55 mg/dl AD IMPROVIG MS OBSERVE AD MAAGE AS APPROPRIATE FS >55 mg/dl AD ASMPTOMATIC START D5S TRASPORT TO ER ECOURAGE PO ITAKE AD DISCHARGE WHE STABLE REPEAT 1 AMP D50W TRASPORT TO ER

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