In a true emergency, every second counts. There are a couple shortcuts that you can take to help you complete the most important steps as efficiently as possible
If a patient in a crisis comes through your door, two of your top priorities are to: provide supplemental oxygen and to obtain venous access. The definition of shock is: inadequate oxygen delivery to this tissues. So providing supplemental oxygen to a patient in shock is a no-brainer. IV catheter placement is also a crucial step in emergency stabilization. This is your lifeline. Having venous access enables you to efficiently administer some of the most valuable life-saving treatments in the ER: medications, drug reversal agents, vasopressors, intravenous fluids and blood products.
When patients are in shock or near death, accessing the veins can be very challenging and time-consuming. You can actually collect your baseline blood samples via the IV catheter during IV catheter placement to save you time. Combining the two procedures also helps to preserve the patient's veins, as many of these patients will ultimately require more than one IV catheter to enable multiple treatments to be given simultaneously.
STAT Emergency Blood Tests
It is nice to run a couple quick, easy "point of care tests." These are some of the most useful parameters to note during an emergency, because they help you to gauge how severe the situation is. It only takes a few seconds to prepare these samples, and there is usually enough blood in the IV catheter stylet to get these tests started. Minimally, I always like to run a baseline PCV/TP, lactate (“how sick are you?”) and blood glucose on emergency patients.
PCV/TP
PCV is code for packed cell volume or hematocrit. It is the percentage of red blood cells in the blood (red blood cell count). A PCV of 20% is considered a "transfusion trigger," so if you see a PCV approaching 20% or in that vicinity, you may need to start making arrangement for the patient to receive a blood transfusion. It is good to know this as soon possible in case you need to call in a blood donor, get blood from another hospital, or possibly arrange for the patient to be transferred to a hospital that has blood products on hand.
TP is the total protein (or total solids). In cases of acute hemorrhage, this may drop before the actual PCV, so it is very useful to have this baseline number in any trauma patient or patient presenting with clinical signs of anemia.
Blood glucose:Measuring the blood glucose requires just one drop of blood on a handheld glucometer (I prefer the Alphatrak glucometer) and reads in less than 5 seconds.
If profound hypoglycemia is present, administering intravenous dextrose can be life-saving (50% Dextrose: 0.25-1 ml/kg; dilute 1:4 with sterile saline prior to administering IV). Determine the cause of the hypoglycemia (the most common scenarios I see in the ER include: insulin overdose in diabetics, sepsis (BIG PROBLEM! if your patient is septic the clock is ticking), and Addison's disease, nutritional (pediatrics/neonates), hepatic disease, and insulinoma.
Lactate (lactic acid levels)One of the first parameters I look at is the lactate level. This tells me- how sick is my patient? How badly is oxygen delivery to the tissues impaired? In my experience, the degree of hyperlactatemia corresponds the degree of compromise. Any elevation in lactate indicates that swift intervention is needed.
A lactate above 6 mmol/L, and the clock is ticking. A lactate level approaching or beyond above the vicinity of 10 mmol/L is a major emergency, and immediate and appropriate intervention is required if the patient is to survive the next hour. These patients should not be put away in a kennel; they should remain in the emergency treatment area as the focus of attention until they have been stabilized.
Stable means: normal heart rate, normal blood pressure, normal lactate levels.
Handheld lactate meters are priceless bedside tools. They only require a drop of blood and it is usually less than 60 seconds to results. In emergency situations, I like to recheck the lactate every 30 minutes until it is normal. Monitoring the lactate helps you assess your progress. If the lactate level is not improving continually with treatment, you should ask yourself what part of oxygen delivery you might be missing (low blood pressure, impaired oxygenation/ventilation, anemia or blood loss?)
If you have that ability to run a very quick STAT emergency panel (with electrolytes, BUN/creatinine), that is great. Checking the potassium level is mandatory in any patient with bradycardia or concern for kidney failure or urinary blockage. Severe hyperkalemia is life-threatening and needs to be addressed right away; very low potassium levels are pretty easy to fix and can speed patient recovery times. Checking blood clotting times (PT/PTT or ACT) is also great in any patient with anemia, bleeding or bruising.
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