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Life Threatening Commonly Seen Medical Conditions in A&E - An Introduction For Paramedics and Medical Students
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Life Threatening Commonly Seen Medical Conditions in A&E - An Introduction For Paramedics and Medical Students


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This is the lecture I gave to the paramedics during a course

This is the lecture I gave to the paramedics during a course

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  • 1. Life Threatening Conditions K.S. CHEW (MD, MMED) Emergency Medicine Department School of Medical Sciences UniversitiSains Malaysia
  • 2. Life Threatening Conditions are conditions that compromise the AIRWAY BREATHING CIRCULATION
  • 3. Overview • Examples of conditions threatening to the: • Airway – Trauma: Facial trauma, facial burns – Non-trauma: anaphylaxis, asthma, foreign bodies airway obstruction • Breathing • Circulation
  • 4. Overview • Examples of conditions threatening to the: • Airway • Breathing – Trauma: Chest trauma – tension pneumothorax, open pneumothorax, flail chest – Non-trauma: asthma, pulmonary embolism • Circulation
  • 5. Overview • Examples of conditions threatening to the: • Circulation – Trauma: Cardiac tamponande – Non-trauma: acute myocardial infarction, acute thoracic dissection
  • 6. AIRWAY
  • 7. Why Airway Management? • Maintain a patent airway • Facilitate mechanical ventilation in respiratory failure • Optimize pulmonary gas exchange; thus prevent hypoxic damage to the brain and other vital organs • Reduce risk of aspiration • Reduce risk of nosocomial pneumonia and assist in removal of bronchial secretions
  • 8. Effects of Hypoxia 0 – 2 min Cardiac Irritability 0 – 4 min Brain damage not likely 4 - 6 min - brain damage possible 6 - 10 min - brain damage very likely More than 10 min - irreversible brain damage
  • 9. Effects of Head- Tilt Chin-Lift Alignment of oral axis, pharyngeal axis and tracheal axis
  • 10. Importance of Opening the Airway The most common cause of ventilation difficulty during resuscitation is an improperly opened airway (AHA Guidelines 2005)
  • 11. Opening the Airway • Lay Rescuer – open the airway using head-tilt chin lift maneuver for non-trauma victims and gentle chin lift for trauma. Jaw thrust no longer recommended because it is difficult to learn and perform, often not effective. • Health Care Provider – Head tilt-chin lift if not trauma. If trauma, apply manual in-line stabilization and jaw thrust.
  • 12. Opening the Airway • If airway obstruction persists despite jaw thrust, attempt head tilt-chin lift even in trauma • This is because maintaining a patent airway and providing adequate ventilation is a priority in CPR (AHA Guidelines 2005) • Furthermore, this complication of damaging the cervical cord has not be documented and the relative risk is unknown (ERC Guidelines 2005)
  • 13. Effects of Head- Tilt Chin-Lift Alignment of oral axis, pharyngeal axis and tracheal axis
  • 14. Remember to protect the cervical spine in cases of trauma
  • 15. Use bags or pillows, etc, to immobilize the cervical spine
  • 17. Oropharyngeal Airways • OPAs are sized by length in centimeters, and are available in sizes for all ages. • A typical adult female will take an 8-cm OPA, and an adult male, 9 or 10 cm.
  • 18. How To Perform? • In adults – insert ‘upside down’ until tip touch hard palate and then rotate 180° before inserting further • Can also insert directly (non-inverted way) with use of tongue depressor • This is preferred in children because of risk of trauma to delicate soft tissue
  • 19. Size of OPA can be estimated from the edge of ear lobe (angle of mandible) to the corner of mouth (incisor teeth)
  • 20. Emergency Care When The Victim is Choking
  • 21. Universal Sign of Choking
  • 22. Performing Heimlich Maneuver (abdominal thrust) only if the upper airway obstruction is complete or near total complete Observe is victim is whether cyanosed, or if his voice becomes muffled or his cough becomes ineffective
  • 23. Position to place your fist between the xiphoid process and the umbilicus
  • 24. Use one hand as the fist. The other hand to grasp the fist and BE PURPOSEFUL and DELIBERATE. Thrust upwards and inwards.
  • 25. If, at any time, the victim collapses, lie him flat and proceed as you would in BLS sequence.
  • 26. Open the airway to see if foreign body is present; if no, attempt rescue breaths (five attempts for two effective breaths) and start chest compression if pulse not present or no signs of life.
  • 28. Examples of Life Threatening Trauma Conditions to the Breathing
  • 29. Initial Assessment/Management in TRAUMA • Primary Survey • Identifies most life-threatening injuries • Resuscitation • Airway control • Ensure oxygenation / ventilation • Needle / tube thoracostomy
  • 30. Life Threatening Conditions In Trauma Primary Survey • Airway obstruction • Tension pneumothorax • Open pneumothorax • Flail chest • Massive hemothorax • Cardiac tamponade
  • 31. Tension Pneumothorax Tension Pneumothorax: Etiology • Parenchymal and/or chest-wall injuries • Air enters pleural space with no exit • Positive pressure ventilation – Collapse of affected lung – Venous return – Ventilation of opposite lung
  • 32. Tension Pneumothorax Tension Pneumothorax: Signs / Symptoms • Respiratory distress • Distended neck veins • Unilateral in breath sounds • Hyperresonance • Cyanosis, late
  • 33. Tension Pneumothorax Tension Pneumothorax • Immediate decompression • Clinical diagnosis, not by x-ray
  • 34. Asthmatic Attack
  • 35. Asthmatic Attack • Asthma sufferers have very sensitive airways, and when they are exposed to certain triggers, their airways narrow making it difficult for them to breathe. • An asthma attack can take anything from a few minutes to a few days to develop
  • 36. Signs and Symptoms • pale, cool, clammy skin • coughing, especially at night • shortness of breath – using all the chest and diaphragm muscles to breathe • ‘sucking in’ of the throat and rib muscles • Severe chest tightness • wheezing – a high pitched raspy sound
  • 37. Signs and Symptoms • cyanosis around the lips (bluish colour) • anxiety and distress • exhaustion • rapid, weak pulse • little or no improvement after using reliever medication (e.g. Bricanyl or Ventolin) • severe asthma attack: collapse – leading to eventual respiratory arrest
  • 38. First Responder Care With spacer • shake inhaler and insert mouthpiece into spacer • place spacer mouthpiece in casualty’s mouth and give 4 separate puffs of a blue/grey reliever puffer
  • 39. First Responder Care Contd… • give 1 puff at a time • ask the casualty to breathe in and out normally 4 times after each puff • wait 4 minutes. If there is little or no improvement, repeat the above sequence
  • 40. First Responder Care Without spacer • shake inhaler • place mouthpiece in casualty’s mouth. • Give 1 puff as the person inhales slowly and steadily
  • 41. First Responder Care contd… • Ask the casualty to hold that breath for 4 seconds, then take 4 normal breaths • Repeat until up to 4 puffs have been given • Wait 4 minutes. If there is little or no improvement, repeat the above sequence
  • 43. Heart Attack
  • 44. The Heart • The normal human heart is a strong, muscular pump a little larger than a fist. • Each day an average heart “beats” (expands and contracts) 100,000 times and pumps about 2,000 gallons of blood. • In a 70-year lifetime, an average human heart beats more than 2.5 billion times.
  • 45. In Myocardial Infarction, time lost is myocardium lost!!
  • 46. Pre-hospital Care of MI Hospital fibrinolysis: Door-to-Needle within 30 min. Not PCI capable EMS on-scene Inter- Onset of 9-1-1 Hospital • Encourage 12-lead ECGs. symptoms of EMS Transfer • Consider prehospital fibrinolytic if STEMI Dispatch capable and EMS-to-needle within PCI 30 min. capable GOALS 5 8 EMS Transport min. min. Patient EMS Prehospital fibrinolysis EMS transport EMS-to-needle EMS-to-balloon within 90 min. within 30 min. Patient self-transport Hospital door-to-balloon Dispatch within 90 min. 1 min. Golden Hour = first 60 min. Total ischemic time: within 120 min.
  • 47. Typical Chest Pain
  • 48. Hollywood Heart Attack
  • 49. Remember With heart attack, every minute counts. If the warning signs are present, do not waste vital moments wondering whether it is a heart attack or not. Take immediate action!
  • 50. First Responder Care to Patient with MI • Recognize and Call (MOST IMPORTANT!) • Rest the casualty in a position of comfort, usually sitting • Assist the casualty to take their medication (nitroglycerine tablets)
  • 51. First Responder Care to Patient with MI • If conscious, give casualty 1/2 an aspirin tablet and have them chew it slowly, unless it is known that the person has been advised not to take aspirin • Reassurance • Stay with the casualty and observe him
  • 52. Pads Position
  • 53. Posterior Position
  • 54. Defibrillation Cardioversion Synchronised on the R Not synchronised wave For For cardiac arrest periarresttachyarrhythmias (unstable) Higher energy joules Lower energy joules No escalating energy for Escalate for next shock next shock (100 - 200 - 300 - 360J)