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  1. 1 EMERGENCY MEDICINE: Principles & Practice Prof. Syed Amin Tabish FRCP (London), FRCP (Edin.), FAMS, MD (AIIMS) Postdoc Fellowship (England) Doctorate in Educational Leadership (USA)
  2. 2 Goals of a Health System  Health is fundamental to quality of life  All human beings have an equal right to heath The Ideal Health system has to achieve:  Attaining Good health for all people  Being responsive to the expectations of the people  Maintaining fairness in allocation of resources for obtaining service
  3. 3 Health For All  The universal goal of the Health System is to ensure adequate access to quality care at a reasonable cost Achieving Health for All requires:  Primary Health Care (Key to HFA)  Emergency Care
  4. 4 Morbidity & mortality  Rapid industrialization & urbanization  Motor Vehicle accidents are the leading cause of death by injury and the 10th. leading cause of all deaths  Violence: political unrest, conflict- related, militancy-related episodes, war  Disasters: natural, man-made including technological disasters  Emergent infection: SARS, Bird flu, Plague, Influenza, etc.
  5. 5 Injury Prevention/Disease Identification Several health care issues have become important to the public and the medical profession:  Real public health threats such as injury, injury prevention, substance abuse, violence, etc.  These issues represent a major cost to society, both in terms of medical expenditures as well as lost productivity.
  6. 6 EMERGENCY MEDICINE Emergency Medicine is in a unique position in the health system:  The interface between community care and hospital care and is usually well integrated with the community services (general practitioner, ambulance service, district nursing), with outpatient services conducted by hospitals and with inpatient services  EM: ideally situated to demonstrate the relationship between these.  The public expects that all medical students and physicians are capable of providing care for medical emergencies - care for all ages and all diseases, either illness or injury.
  7. 7 EM: Scope  Patients present to Emergency Departments with problems rather than diseases, highlighting the importance of a problem- based approach to clinical decision making  Emergency Medicine is integrated both horizontally (with other clinical disciplines) and vertically (with basic science and applied science disciplines). Emergency Medicine is Multidisciplinary.  These features make Emergency Departments ideal learning environments for medical students.
  8. 8 EM: Scope (contd.)  All doctors should possess general skills and knowledge regarding emergency care of the acutely ill or injured patient.  There is a need for every medical school graduate to handle emergencies as they arise in the daily practice of medicine.  The assessment and management of emergencies is a central component of medical education encompassing principles that apply to all clinical disciplines.
  9. 9 EM: Scope (contd.)  The emergency department (ED) provides a unique educational experience that is distinct from both inpatient and ambulatory care settings.  Because of the high acuity, interesting pathology, and rapid patient turnover, the ED is an ideal location to train medical students. Numerous teaching opportunities exist within the domain of the ED.  OBJECTIVE: Saving lives and limbs, reducing disability
  10. 10 Scope (contd.) Encounters such as the acutely poisoned or intoxicated patient, environmental emergencies, interaction with out-of- hospital providers, and patients requiring emergency procedures are just a few situations that make emergency medicine a distinct clinical specialty. Essential elements to create a progressive learning environment over the entire undergraduate educational experience include:  Resuscitation room  The undifferentiated problem  Health system management  Common minor problems
  11. 11 EM: Unique Content Content areas unique to EM include: Out-of-hospital care involves medical care in the community.  Toxicology offers the medical student a good correlation between biochemistry, pharmacology, and clinical medicine. Many poisoned patients also require resuscitative and critical care skills.  Environmental disease and injuries such as bites and stings, dermatitis, burns, disorders of temperature, near drowning or lightning injuries commonly present in the ED.
  12. 12 Components of EM  Cardiopulmonary resuscitation  Basic first aid  ED/EMS observation  Injury prevention/disease identification  Approach to patient with life or limb threatening disease - case correlation with pathology, pharmacology, pathophysiology courses.  Procedures - suturing, splinting, basic airway management, intubation, IVs, NGT placement  Focus on the acutely ill or injured patient  The coordination of treatment with other physicians and health services.
  13. 13 Triage  Medical prioritization and triage decision making  Triage is the process used to sort patients in order of acuity or the severity of illness  Right Patient at Right Place at the Right Time  The utilization of scant resources and the ability to prioritize care with minimal or incomplete information
  14. 14 Resuscitation Presentations  Major topics to be addressed include: "collapse", chest pain, shortness of breath, altered conscious state and the multiply injured patient.  Procedures appropriate to this section are basic life support, advanced cardiac life support and the assessment and management of the multiply injured. The emphasis is on rapid assessment skills and airway, breathing and circulation procedures.
  15. 15 The Undifferentiated Problem  Many patients present to ED with undifferentiated problems for example abdominal pain, headache and dyspnoea  Students should learn about linking the clinical task with clinical decision making and practice.  Also know how to use investigations to assist (not direct) the decision making process.
  16. 16 The Undifferentiated Problem (contd.) Procedures include: • history taking • clinical examination • documenting of findings • charting and measurement of vital signs including pulse, blood pressure, temperature and Glasgow Coma Score • performance of bedside tests such as urinalysis, ECG, venepuncture, intravenous access, catheterization of the bladder and stomach and administration of oxygen and nebuliser therapy.
  17. 17 Other Common Problems  A number of non-life threatening problems include the assessment and management of soft tissue injuries and infections, extremity injuries, burns and otolarygological (ENT) and ophthalmological problems.  Relevant procedures to be learnt include examination of the neurovascular system, tendons, ears, eyes, nose and throat, local anesthetic techniques, soft tissue injury repair, joint dislocations and the reduction and management of minor fractures.
  18. 18 General Skills General Assessment Skills Such skills include:  focused patient history  physical diagnosis  medical decision making  exposure to a broad base of "undifferentiated" patients and a wide variety of personal and social issues that influence patient care.
  19. 19 Life-saving Resuscitation Skills All physicians should learn recognition of life-threatening situations and initiation of resuscitation skills.
  20. 20 Life - saving procedures  Airway management and intubation  Augmentation of circulation  Hemorrhage control  Limb stabilization  Suturing  Splinting  Central line insertion  Defibrillation  Respiratory and circulatory support, IV's, NGT's  Neurologic treatment  care for the acutely psychotic and the poisoned patient
  21. 21 EM: Clerkship  Perform an appropriately directed history and physical examination  Recognize emergent and urgent problems  Develop a differential diagnosis for common presenting complaints such as chest pain, shortness of breath, abdominal pain.  Develop an appropriate and cost-effective management plan for the ED patient presenting with common complaints such as acute asthma exacerbation, congestive heart failure, bronchitis, etc.  Demonstrate proper wound care and suture technique for simple lacerations.
  22. 22 EM Clerkship (contd.)  Recognize ischemic patterns and arrhythmias on EKG tracings.  Appropriately interpret results of complete blood count, chemistries, urinalysis, arterial blood gases, and the common laboratory studies.  Appropriately interpret radiographs (X ray) of the chest, abdomen, and extremities.  Recognize the indications for specialty or subspecialty consultation.
  23. 23 Toxicology/Hazmat Know the principles of:  biochemistry  pharmacology  pathophysiology as they relate to poisoning and hazardous material
  24. 24 Trauma  One of the leading causes of disability and premature death  Know the epidemiology, pathophysiology and principles of treatment.
  25. 25 Specific Patient Care Specific clinical conditions: The approach to the patient with: short of breath altered mental status chest pain multiple injuries hypertension  pregnant patient The pediatric patient
  26. 26 Other Skills  To gain first-hand experience with airway management (bag-valve-mask and oxygen administration, etc.), hemorrhage control, fluid resuscitation, limb stabilization and CPR in the ED  Universal Precautions to be observed  Emergency Preparedness - Code Blue: for management of Cardiopulmonary Arrest - Code Yellow: for poly trauma/ mass casualties - Code Green/Black: Disaster Management  Legal Aspects of Emergency Care
  27. 27 Management of the Health Care System  Emergency physicians often act as "gatekeepers" and are responsible for the coordination of a patient's care among outpatient clinics, observation services and patient transfer.  The ED provides an ideal environment to educate the medical student on appropriate consultation practices and referral to other health care services, while providing cost-efficient care.
  28. 28 MINIMUM LIBRARY RECOMMENDATIONS  Cambridge Textbook of Accident and Emergency Medicine edited by David V Skinner, J W Rodney Peyton, Colin E Robertson, Andrew Swain  Emergency Medicine: A Comprehensive Study Guide by American College of Emergency Physicians  Principles and Practice of Emergency Medicine by Schwartz, George R. Baltimore: Williams & Wilkins, 1999.  Emergency Medicine Manual by O. John Ma, David M. Cline, Judith E. Tintinalli  Emergency Medicine: Concepts and clinical practice Eds: Rosen P, Baker FJ, Barkin RM
  29. 29 JOURNALS  Emergency Medicine. Australasian Society for Emergency Medicine.  Annals of Emergency Medicine. American College of Emergency Physicians  Journal of Emergency Medicine. Permagon Press  Emergency Clinics of North America. WB Saunders Company  Emergency Medical Abstracts. Ed: Hasapes GA  Medline
  30. 30 THANK YOU
  31. 31 THANK YOU
  32. 32 Head trauma Injuries are the leading cause of death in children, and brain injury is the most common cause of pediatric traumatic death. The automobile is the most lethal component of a child's environment.
  33. 33 • 200-300/100,000 per annum • $7.5 Billions per annum in the USA • multiple aetiologies – automobiles – abuse – falls (bikes, skateboards, ATVs, walkers,windows) – missiles (lawn darts, bullets) Head trauma: statistics
  34. 34
  35. 35 • diffuse axonal injury • brainstem injury • bilateral hemispheric damage Coma can result from: Coma can result from:
  36. 36 Subdural Subdural vs. vs. epidural epidural LifeArt: Williams & Wilkins LifeArt: Williams & Wilkins
  37. 37 • is venous in origin (bridging veins) • is associated with a reasonable outcome if removed early Subdural hematoma I Subdural hematoma I WebPath: University of Utah WebPath: University of Utah http://www http://www-
  38. 38 • is venous in origin (bridging veins) • is associated with a reasonable outcome if removed early Subdural hematoma II Subdural hematoma II WebPath: University of Utah WebPath: University of Utah http://www http://www-
  39. 39 • usually arise from the bridging veins • bridging veins are more susceptible to tearing when there is cortical atrophy Subdural hematoma III Subdural hematoma III WebPath: University of Utah WebPath: University of Utah http://www http://www-
  40. 40 • video of subdural hematoma resection • dura is bluish, discolored, tense • pressure on cortex relieved upon resection of dura Subdural hematoma resection Subdural hematoma resection DogByte Productions DogByte Productions Oregon Health Sciences University Oregon Health Sciences University QuickTime™ and a Sorenson Video decompressor are needed to see this picture.
  41. 41 • is arterial in origin • middle meningeal artery is torn • often is a true neurosurgical emergency Epidural hematoma I Epidural hematoma I WebPath: University of Utah WebPath: University of Utah http://www http://www-
  42. 42 Epidural hematoma II Epidural hematoma II WebPath: University of Utah WebPath: University of Utah http://www http://www-
  43. 43 Hematoma: distortion • hematoma displaces brain toward the right • strain or distortion of brain tissue visualized colorimetrically: deep blue low distortion, and yellow and red high distortion or stretching • in this case there is about 17% distortion
  44. 44 Hematoma: interstital pressure • interstitial pressure is depicted • although the midbrain is in contact with the tentorial incisura, the most greatly affected perfusion is within the ipsilateral hemisphere
  45. 45 • is usually frontal or temporal lobe • can be bilateral (contracoup injury) Intracerebral Intracerebral hemorrhage hemorrhage
  46. 46 • is usually frontal or temporal lobe Focal injury Focal injury WebPath WebPath: University of Utah : University of Utah http://www http://www-
  47. 47 • a fall backwards resulted in bilateral injury • inferior frontal and temporal lobes Coup Coup - - contracoup contracoup injury injury WebPath WebPath: University of Utah : University of Utah http://www http://www-
  48. 48
  49. 49 Cerebral perfusion scan Cerebral perfusion scan
  50. 50 Cerebral perfusion scan II Cerebral perfusion scan II
  51. 51 Thank you
  52. 52