Introduction_vista

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EMERGENCY MEDICINEEMERGENCY MEDICINE

AbdulhadiAbdulhadi TashkandiTashkandiMD,FRCP(c)EM consultantResidency training program director KAMC-J


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AbdulhadiAbdulhadiTashkandiTashkandiEM consultantResidency training program director, KAMC-J

MD KAAU 1995

FRCP(c) Residency at McGill University

Graduated 2004

ACEP (American College of Emergency

Physicians) Teaching Fellowship

According to the National Hospital

Ambulatory Care Survey an estimated 110million visits were made to hospital

emergency departments in 2002.

This is an increase of 23% since 1992 (89

million ED visits).


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A-6

Top Ten Leading Causes of Death in the U.S.

Heart Disease: 726,974

Cancer: 539,577

Stroke: 159,791

Chronic Obstructive Pulmonary Disease: 109,029

Accidents: 95,644

Pneumonia/Influenza: 86,449

Diabetes: 62,636

Suicide: 30,535

Nephritis, Nephrotic Syndrome, and Nephrosis25,331

Chronic Liver Disease and Cirrhosis: 25,175


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What is Emergency medicine?

A medical specialty concerned with

resuscitation, transportation, andcare from the point of injury or

beginning of illness through thehospital or other emergency

treatment facility.


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Emergency Medicine

is a specialty of medicine that focuses on thediagnosis and treatment of acute illnesses andinjuries that require immediate medicalattention.

While not usually providing long-term orcontinuing care, emergency medicinephysicians diagnose a wide array of pathologyand undertake acute interventions to stabilize

the patient.

The emergency physician requires a broad field ofknowledge and advanced procedural skills oftenincluding surgical procedures, trauma resuscitation,advanced cardiac life support and advanced airwaymanagement.

Emergency physicians ideally have the skills of manyspecialists ;

the ability to manage a difficult airway (ANESTHESIA),

suture a complex laceration (PLASTIC SURGERY),

reduce (set) a fractured bone or dislocated joint(ORTHOPEDIC SURGERY),

treat a heart attack (INTERNIST), work-up a pregnant patient with vaginal bleeding

(OBSTETRICS AND GYNECOLOGY), and

stop a bad nosebleed (ENT).

Others..


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A landmark article by Schneider, et al. from theEM literature defines our specialty as one with the principle mission of evaluating,managing, treating and preventing unexpectedillness and injury.

As emergency medical care is an essentialcomponent of a comprehensive health caredelivery system, it must be available 24 hrs a

day. EPs provide rapid assessment and treatment of

any patient with a medical / surgical emergency.

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Appeal of Emergency Medicine

Make an immediate difference

Life threatening injuries and illnesses

Undifferentiated patient population

Challenge of anything coming in

Emergency / invasive procedures

Safety net of healthcare


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Appeal of Emergency Medicine

Team approach

Patient advocacy

Open job market

Academic opportunities

Shift work / set hours

Evolving specialty

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Downside to Emergency Medicine

Very wide knowledge base requirement

Interaction with difficult, intoxicated, or

violent patients

Under-estimation of the specialty

Shift work

Difficult as a private business 24/7 availability

Team play


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PRINCIPLES OF EMERGENCY

MEDICINEA. Is the Patient About to Die?

Every patient's presentation is quickly prioritized

to one of the following acuities:

Critical

Emergent

Non-urgent

Look for symptoms of a life-threatening

emergency, not a specific disease entity.

PRINCIPLES OF EMERGENCYMEDICINE

B. What Steps Must Be Undertaken to

Stabilize the Patient?

To stabilize the critically ill or injured patient.

Primary survey (airway, breathing,circulation, and neurologic deficits.


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MEDICINEC. What Are the Most Potential Serious

Causes of the Patient's Presentation?

Thinking worst-case scenario, "What will killmy patient the fastest?" .

Once the list has been developed, the vitalsigns, history, physical examination, and

ancillary assessments should identify orconfirm those causes highest on the list.


D. Could There Be Multiple Causes of the

Patient's Presentation?

In addition to constant reevaluation andreprioritization of the differential diagnosis,continually ask, "Is this all there is?

Frequent reassessment and thoughtful inquiryas to the multiple possibilities responsible for

each patient's condition is imperative.


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MEDICINEE. Can a Treatment Assist in the Diagnosis

in an Otherwise Undifferentiated Illness?

The patient's response to empiricadministration of naloxone will include orexclude narcotic overdose as a contributor tothe obtundation.

Referred to as the "diagnostic-therapeutic"concept,


F. Is a Diagnosis Mandatory or Even

Possible?

Determining the disposition for a

nonemergency patienthaving treated

their symptoms and excluding emergency

conditions without a specific diagnosis.

If the Patient Is Not Being Admitted, Is the

Disposition Safe and Adequate for the

Patient?


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MEDICINEG. Does This Patient Need to be Admitted

to the Hospital?

Making the bottom-line disposition decision.

Does the patient have timely accessiblefollow-up?

Are you, as the EP, comfortable dischargingthe patient?

Patient acuity definitions

CriticalCritical

Patient presents with signs orsymptoms of a life-threatening illness

or injury with a high probability ofmortality if immediate intervention is

not begun to prevent further airway,respiratory, hemodynamic, and/or

neurologic instability.


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EmergentEmergent

Patient presents with signs or

symptoms of an illness or injury thatmay progress in severity or result in

complications with a high probability formorbidity if treatment is not begun

quickly.


Lower AcuityLower Acuity

Patient presents with signs or

symptoms of an illness or injury thathave a low probability of rapid

progression to more serious disease or

development of complications.


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INITIAL PATIENT ASSESSMENT AND

MANAGEMENT APPROACH 5 level triage

(Canadian Guidelines)

I Resuscitation

II Emergent

III Urgent

IV Less-urgentV Non-urgent

Level I: Resuscitative

Conditions that are threats to life or

limb (or imminent risk ofdeterioration) requiring aggressiveinterventions.

Time to MD: Immediate

Time to Nurse: Immediate


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Level II: Emergent

Conditions that are a potential threat

of life, limb or function, requiringrapid medical intervention ordelegated acts.

Time to MD: 15 mins

Time to Nurse: immediate

Level III: Urgent

Conditions that could potentially progressto a serious problem requiring emergency

intervention. May be associated withsignificant discomfort or affecting ability

to function at work or activities of daily

living. Time to MD:


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Level IV: Less Urgent

Conditions that related to patient age,

distress, or potential for deterioration orcomplications would benefit fromintervention or reassurance within 1 2

hours)

Time to MD < 60 minutes (1 hr)

Time to Nurse < 60 minutes (1 hr)

Level V: Non Urgent

Conditions that may be acute but non-urgent aswell as conditions which may be part of a chronicproblem with or without evidence ofdeterioration.

The investigation or interventions for some ofthese illnesses or injuries could be delayed oreven referred to other area of the hospital or

health care system. Time to MD: 120 minutes

Time to Nurse: 120 minutes


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A 55-year old hypertensive diabetic male withcrushing chest pain, diaphoresis, and a bloodpressure of 60 systolic who is clutching hischest.

Acuity Frame: Critical

Implications: Immediate intervention isnecessary to manage and stabilize vital

functions. High probability of mortality existswithout immediate intervention.

A 74-year old female with a history of anginapresenting with three-to-five minutes of dullchest pain typical of her angina. She has stablevital signs and her pain is relieved bynitroglycerin.

Acuity Frame: Emergent

Implications: Initiation of monitoring, vascularaccess, evaluation, and treatment must beperformed quickly. Progression in severity,complications, or morbidity may occur withoutimmediate treatment.


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A 12-year old female with non-traumatic

sharp chest pain lasting for several days thatintensifies with movement of the torso.

Acuity Frame: Lower acuity

Implications: Patients symptoms should be

addressed promptly. However, progression tomajor complications would be unlikely.

INITIAL PATIENT ASSESSMENT ANDMANAGEMENT

PRIORITIZED PLAN

1. Rapid Primary Survey

2. Resuscitation (often occurs atsame time as 1)

3. Detailed Secondary Survey4. Definitive Care


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RAPID PRIMARY SURVEY

A irway maintenance with C-spine

control

B reathing and ventilation

C irculation (pulses, hemorrhage control)

D isability (neurologic status)

E xposure (complete) and E nvironment(temperature control) restart sequence

from beginning if patient deteriorates

A B C

Performing ABC on each and every pt. , you

minimize the chance of missing a LIFETHREATENING problem.


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A. AIRWAY

first priority is to secure airway

assume a cervical (C-spine) injury in every traumapatient > immobilize with collar and sand bags

Causes of Airway Obstruction

decreased level of consciousness (LOC)

airway lumen: foreign body (FB), vomit

airway wall: edema, fractures

external to wall: lax muscles (tongue), directtrauma, expanding hematoma


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Airway Assessment

assess ability to breathe and speak

signs of obstruction noisy breathing is obstructed breathing until proven

otherwise

respiratory distress

failure to speak, dysphonia

adventitous sounds

cyanosis

agitation, confusion, universal choking sign

think about ability to maintain patency in futurecan change rapidly,

ALWAYS REASSESS

Airway Management

goals

achieve a reliably patent airway

permit adequate oxygenation andventilation

facilitate ongoing patient management

give drugs via endotracheal tube (ETT) if IVnot available:

NABEL: N arcan, Atropine, B-agonists

(Ventolin),Epinephrine, Lidocaine


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Airway Management

start with basic management techniquesthen progress to advanced

1. Basic Management (Temporizing Measures)

protect the C-spine

chin lift or jaw thrust to open the airway

sweep and suction to clear mouth of foreign material

nasopharyngeal airway

oropharyngeal airway (not if gag present)transtracheal jet ventilation (through cricothyroid

membrane) used as last resort, if unable toventilate after using above techniques

Airway Management

2. Definitive Airway

Endotracheal intubation (ETT)

Orotracheal

Rapid Sequence Intubation (RSI)

Nasotracheal

may be better tolerated inconscious patient


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Airway Management

indications for intubation

unable to protect airway

inadequate spontaneous ventilation

O 2 saturation < 90% with 100% O2

profound shock

GCS = 8

anticipate in trauma, overdose, congestive heartfailure (CHF), asthma, and chronic obstructivepulmonary disease (COPD)

anticipated transfer of critically ill patients

Airway Management

surgical airway (if unable to intubate using

oral/nasal route)

needed for chemical paralysis of agitated

patients for investigations

cricothyroidotomy


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B. BREATHING LOOK

mental status (anxiety, agitation), colour, chest movement, respiratory

rate/effort

FEEL flow of air, tracheal shift, chest wall for crepitus, flail segmentsand sucking

chest wounds, subcutaneous emphysema,

LISTEN sounds of obstruction (e.g. stridor) during exhalation, breath soundsand

symmetry of air entry, air escaping

Oxygenation and Ventilation measurement of respiratory function: rate, pulse oximetry, ABG, A-a

gradient, peak flow rate


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C. CIRCULATION-

stop major external bleeding apply direct pressure

elevate profusely bleeding extremities if no obvious unstablefracture

consider pressure points (brachial, axillary, femoral) do not remove impaled objects as they tamponade bleeding use tourniquet as last resort

treatment 2 large bore peripheral IVs for shock (14-16 gauge)

bolus with Ringers lactate (RL) or normal saline (NS) (2litres) and then blood as indicated

for hypovolemic shock inotropes for cardiogenic shock

vasopressors for septic shock

D. DISABILITY

assess level of consciousness by AVPU

method (quick, rudimentary assessment)

A - A LERT

V - responds to V ERBAL stimuli

P - responds to P AINFUL stimuli

U - U NRESPONSIVE

size and reactivity of pupils movement ofupper and lower extremities (UE/LE)


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Glasgow Coma Scale

E. EXPOSURE / ENVIRONMENT

undress patient completely

essential to assess all areas for possible injury

keep patient warm with a blanket +/ radiantheaters; avoid hypothermia


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THE END

1. Introduction and BLS review

2. Approach to coma and Alt . LOC3. Trauma approach (introduction to ATLS)

4. Introduction to ACLS

5. Approach to chest pain / ACS

6. Introduction to Shock management

7. General Principles of Orthopedic Injuries / Approach to the orthopedic examination

8. Abdominal pain in ED

9. Acute SOB

10. Approach to the Poisoned Patient

11. Approach to GI bleeding

12. Approach to common CNS presentations (headache, dizziness, seizures..)

13. Approach to endocrine emergencies

14. Approach to emergency infectious diseases

15. Approach to ENT / Ophthalmologic emergencies

16. Approach to the Pregnant Patient / gynecologic emergencies

17. Environmental emergencies

18. General Approach to the Pediatric Patient in the Emergency Department


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Extra sessions:

Basic ECG reading

CXR approach

ED vital tools

Recommended procedures to beperformed during the rotation Venipuncture

Arterial blood gas

Incision and drainage (abscess)

Infiltration of local anesthesia

Laceration repair (sutures)

Lumbar puncture

NG tube insertion

Splinting (ankle, forearm/wrist)


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http://www.medicalstudent.com/

http://medicalppt.blogspot.com/search/label/

EMERGENCY%20MEDICINE

Pearls, pitfalls, and myths

Limited history from limited sources

Incomplete review of systems

Incomplete review of medications withoutconsidering drugdrug interactions or adverseeffects

Failure to document vital signs

Failure to address abnormal vital signs

Limited or incomplete physical examination,including neurologic

Unreasonable assumption of psychiatric illnesswithout considering medical or traumatic etiologiesor ingestion and intoxication.


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