Emergency medicine


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Emergency medicine

  1. 1. 1
  2. 2. EMERGENCY MEDICINE: Principles & Practice Prof. Syed Amin Tabish FRCP (London), FRCP (Edin.), FAMS, MD 2
  3. 3. 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
  4. 4. 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
  5. 5. Morbidity & mortality  Rapid industrialization & urbanization  Motor Vehicle accidents are the leading cause of death by injury and the 10 th. leading cause of all deaths  Violence: political unrest, conflictrelated, militancy-related episodes, war  Disasters: natural, man-made including technological disasters  Emergent infection: SARS, Bird flu, Plague, Influenza, etc. 5
  6. 6. 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
  7. 7. 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
  8. 8. EM: Scope  Patients present to Emergency Departments with problems rather than diseases, highlighting the importance of a problembased 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
  9. 9. 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
  10. 10. 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
  11. 11. Scope (contd.) Encounters such as the acutely poisoned or intoxicated patient, environmental emergencies, interaction with out-ofhospital 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
  12. 12. 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
  13. 13. Components of EM  Cardiopulmonary  Basic resuscitation 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
  14. 14. 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
  15. 15. 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
  16. 16. 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
  17. 17. 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
  18. 18. 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
  19. 19. 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
  20. 20. Life-saving Resuscitation Skills All physicians should learn recognition of life-threatening situations and initiation of resuscitation skills. 20
  21. 21. 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
  22. 22. 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
  23. 23. 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
  24. 24. Toxicology/Hazmat Know the principles of:  biochemistry  pharmacology  pathophysiology as they relate to poisoning and hazardous material 24
  25. 25. Trauma One of the leading causes of disability and premature death  Know the epidemiology, pathophysiology and principles of treatment.  25
  26. 26. 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
  27. 27. 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
  28. 28. 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
  29. 29. 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: Guide A Comprehensive Study 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 practice Medicine: Concepts and clinical Eds: Rosen P, Baker FJ, Barkin RM 29
  30. 30. 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
  31. 31. THANK YOU 31
  32. 32. THANK YOU 32
  33. 33. Head trauma Injurie s a re the le a ding ca us e of de a th in childre n, a nd bra in injury is the mos t common ca us e of pe dia tric tra uma tic de a th. The a utomobile is the mos t le tha l compone nt of a child's e nvironme nt. 33
  34. 34. Head trauma: statistics • 200-300/100,000 pe r a nnum • $7.5 Billions pe r a nnum in the US A • multiple a e tiologie s – – – – a utomobile s a bus e fa lls (bike s , s ka te boa rds , ATVs , wa lke rs ,windows ) mis s ile s (la wn da rts , bulle ts ) 34
  35. 35. Pediatric head trauma • ma tura tiona l diffe re nce s ha ve implica tions for a s s e s s me nt a nd prognos tica tion – the young child's bra in pre s e nts a diffe re nt de ve lopme nta l s ubs tra te for injury 35
  36. 36. Coma can result from: • diffus e a xona l injury • bra ins te m injury • bila te ra l he mis phe ric da ma ge 36
  37. 37. Subdural vs . epidural LifeArt: Williams & Wilkins http://www.lifeart.com 37
  38. 38. Subdural hematoma I • is ve nous in origin (bridging ve ins ) • is a s s ocia te d with a re a s ona ble outcome if re move d e a rly WebPath: University of Utah http://www-medlib.med.utah.edu/WebPath/webpath.html 38
  39. 39. Subdural hematoma II • is ve nous in origin (bridging ve ins ) • is a s s ocia te d with a re a s ona ble outcome if re move d e a rly WebPath: University of Utah http://www-medlib.med.utah.edu/WebPath/webpath.html 39
  40. 40. Subdural hematoma III • us ua lly a ris e from the bridging ve ins • bridging ve ins a re more s us ce ptible to te a ring whe n the re is cortica l a trophy WebPath: University of Utah http://www-medlib.med.utah.edu/WebPath/webpath.html 40
  41. 41. Subdural hematoma resection • • dura is bluis h, dis colore d, te ns e • QuickTime™ and a Sorenson Video decompressor are needed to see this picture. vide o of s ubdura l he ma toma re s e ction pre s s ure on corte x re lie ve d upon re s e ction of dura DogByte Productions Oregon Health Sciences University 41
  42. 42. Epidural hematoma I • is a rte ria l in origin • middle me ninge a l a rte ry is torn • ofte n is a true ne uros urgica l e me rge ncy WebPath: University of Utah http://www-medlib.med.utah.edu/WebPath/webpath.html 42
  43. 43. Epidural hematoma II WebPath: University of Utah http://www-medlib.med.utah.edu/WebPath/webpath.html 43
  44. 44. Hematoma: distortion • he ma toma dis pla ce s bra in towa rd the right • s tra in or dis tortion of bra in tis s ue vis ua lize d colorime trica lly: de e p blue low dis tortion, a nd ye llow a nd re d high dis tortion or s tre tching • in this ca s e the re is a bout 17% dis tortion http://www.neurosurgery-neff.com/trauma_research.html 44
  45. 45. Hematoma: interstital pressure • inte rs titia l pre s s ure is de picte d • a lthough the midbra in is in conta ct with the te ntoria l incis ura , the mos t gre a tly a ffe cte d pe rfus ion is within the ips ila te ra l he mis phe re http://www.neurosurgery-neff.com/trauma_research.html 45
  46. 46. Intracerebral hemorrhage • is us ua lly fronta l or te mpora l lobe • ca n be bila te ra l (contracoup injury) 46
  47. 47. Focal injury • is us ua lly fronta l or te mpora l lobe WebPath: University of Utah http://www-medlib.med.utah.edu/WebPath/webpath.html 47
  48. 48. Co up - c o ntra c o up injury • a fa ll ba ckwa rds re s ulte d in bila te ra l injury • infe rior fronta l a nd te mpora l lobe s WebPath: University of Utah http://www-medlib.med.utah.edu/WebPath/webpath.html 48
  49. 49. Co up - c o ntra c o up injury LifeArt: Williams & Wilkins http://www.lifeart.com 49
  50. 50. Cerebral perfusion scan 50
  51. 51. Cerebral perfusion scan II 51
  52. 52. Thank you 52