Advanced life support (ALS). a higher level of emergency medical care, usually provided by EMT-intermediates or paramedics.

1. EMERGENCIES IN
GENERAL PRACTICE
By
Dr . NADER ALDABOUR

2. Cardiac emergencies
• The signs and symptoms of cardiac emergencies include chest
pain ! , shortness of breath, fast and slow heart rates, increased
respiratory rate, low blood pressure ! , poor peripheral perfusion
(indicated by prolonged capillary refill time) and altered mental
state.
• If there is a history of angina the patient will probably carry
glyceryl trinitrate spray or tablets (or isosorbide dinitrate tablets)
and they should be allowed to use them.
• Where symptoms are mild and resolve rapidly with the patient’s
own medication, hospital admission is not normally necessary.
• Sudden alterations in the patient’s heart rate (very fast or very
slow) may lead to a sudden reduction in cardiac output with loss
of consciousness.
• Medical assistance should be summoned by dialling 999.

3. Case. Myocardial infarction
Symptoms and signs of myocardial infarction
• Progressive onset of severe, crushing pain in the centre
and across the front of chest. The pain may radiate to the
shoulders and down the arms (more commonly the left),
into the neck and jaw or through to the back.
• Skin becomes pale and clammy.
• Nausea and vomiting are common.
• Pulse may be weak and blood pressure may fall.
• Shortness of breath.

5. localisation ST elevation Reciprocal ST depression coronary artery
Anterior MI V1-V6 None LAD
Septal MI
V1-V4, disappearance of septum Q in
leads V5,V6
none LAD-septal branches
Lateral MI I, aVL, V5, V6 II,III, aVF LCX or MO
Inferior MI II, III, aVF I, aVL RCA (80%) or RCX (20%)
Posterior MI V7, V8, V9
high R in V1-V3 with ST depression
V1-V3 > 2mm (mirror view)
RCX
Right Ventricle MI V1, V4R I, aVL RCA
Help with the localisation of a myocardial infarct

6. Case. Myocardial infarction
• Call 999 immediately for an ambulance.
• Allow the patient to rest in the position that feels most comfortable;
in the presence of breathlessness this is likely to be the sitting
position. Patients who faint or feel faint should be laid flat; often an
intermediate position (dictated by the patient) will be most
appropriate.
• Give high flow oxygen (10 litres per minute).
• Give sublingual GTN spray if this has not already been given.
• Reassure the patient as far as possible to relieve further anxiety.
• Give aspirin in a single dose of 300 mg orally, crushed or chewed.
Ambulance staff should be made aware that aspirin has already been
given as should the hospital.
• Many ambulance services in the UK will administer thrombolytic
therapy before hospital admission.
• If the patient becomes unresponsive always check for ‘signs of life’
(breathing and circulation) and start CPR in the absence of signs of
life or normal breathing (ignore occasional ‘gasps’).

7. WITHOUT
AED

8. WITH
AED

9. TRAUMA.
.

10. CASE - TRAUMA
Trauma Assessment
The initial assessment and management of seriously
injured patients is a challenging task and requires a rapid
and systematic approach. This systematic approach can
be practised to increase speed and accuracy of the
process but good clinical judgement is also required.
Although described in sequence some of the steps will
be taken simultaneously.
The aim of good trauma care is to prevent early trauma
mortality. Early trauma deaths occur because of failure
of oxygenation of vital organs or central nervous system
injury or both.

11. CASE – TRAUMA MANAGEMENT
First and most important:
Is it safe to approach?

12. CASE – TRAUMA MANAGEMENT
•Aims of the initial evaluation of trauma patients
• Stabilise the patient
• Identify life threatening conditions in order of risk and initiate
supportive treatment
• Organise definitive treatments or organise transfer for definitive
treatments
•Preparation and coordination of care Assessment and
management will begin out of hospital at the scene of injury
and good communication with the receiving hospital is
important. The preparatory measures are outlined below to
'set the scene':

13. CASE – TRAUMA MANAGEMENT
• The prehospital phase
• Preparation of a resuscitation area
• Airway equipment (laryngoscopes etc accessible, tested)
• Intravenous fluids (warming equipment etc)
• Immediately available monitoring equipment
• Methods of summoning extra medical help
• Prompt laboratory and radiology backup
• Transfer arrangements with trauma centre.
• Guidelines on protection when dealing with body fluid should be
followed throughout this and subsequent procedures.

14. CASE – TRAUMAMANAGEMENT
General principles
1. Follow the Airway, Breathing, Circulation, Disability, and Exposure approach
(ABCDE) to assess and treat the patient.
2. Treat life-threatening problems as they are identified before moving to the next
part of the assessment.
3. Continually re-assess starting with Airway if there is further deterioration.
4. Assess the effects of any treatment given.
5. Recognise when you need extra help and call for help early. This may mean
dialling 999 for an ambulance.
6. Use all of your resources – ask members of public for help. This will allow you to
do several things at once, e.g., collect emergency drugs and equipment, dial 999.

15. CASE – TRAUMA MANAGEMENT
Initial assessment
This comprises:
• Primary survey
• Resuscitation
• Secondary survey
• Definitive treatment or transfer for definitive care

16. CASE – TRAUMA MANAGEMENT
• A= Airway maintenance cervical spine protection
• B= Breathing and ventilation
• C= Circulation with haemorrhage control
• D= Disability: Neurological status
• E= Exposure/ environmental control

17. CASE – TRAUMA MANAGEMENT
As part of the secondary survey
•History:
• A=Allergies
• M=Medication currently used
• P=Past illnesses/Pregnancy
• L=Last meal
• E=Events/Environment related to injury

18. CASE – TRAUMA MANAGEMENT
A= Airway maintenance cervical spine protection
• Are there signs of airway obstruction, foreign bodies, facial,
mandibular or laryngeal fractures?
• Establish a clear airway (chin lift or jaw thrust) but protect the cervical
spine at all times. If the patient can talk the airway is likely to be safe
but remain vigilant and recheck. GCS less than 8 requires definitive
airway.

19. CASE – TRAUMA MANAGEMENT
B= Breathing and ventilation
Evaluate breathing:
lungs, chest wall, diaphragm. Chest examination with adequate
exposure: watch chest movement, auscultate, percuss to detect
lesions acutely impairing ventilation:
• Tension pneumothorax
• Flail chest
• Haemothorax
• Pneumothorax.

20. CASE – TRAUMAMANAGEMENT
C = Circulation with haemorrhage control
• Blood loss is the main preventable cause of death after trauma. To assess blood loss rapidly
observe:
• Level of consciousness
• Skin colour
• Pulse.
• Bleeding should be assessed and controlled:
• Direct manual pressure should be used (not tourniquets except for traumatic
amputation as these cause distal ischemia).
• Transparent pneumatic splinting devices may control bleeding and allow visual
monitoring.
• Occult bleeding into the abdominal cavity and around long bone or pelvic
fractures is problematic.

22. CASE – TRAUMA MANAGEMENT
D = Disability: Neurological status
• After A,B and C above rapid neurological assessment is made to establish
• Level of consciousness, using Glasgow Coma Scale
• Pupils: size, symmetry and reaction
• Any lateralising signs
• Level of any spinal cord injury (limb movements, spontaneous respiratory effort)
• Note: remember oxygenation, ventilation, perfusion, drugs, alcohol and
hypoglycaemia may all also affect level of consciousness.

23. CASE – TRAUMA MANAGEMENT
E= Exposure/ environmental control
• Undress patient, but prevent hypothermia Clothes may need
to be cut off, but after examination attention to prevention
of heat loss with warming devices, warmed blankets etc is
important, Intravenous fluids should be warmed before
infusion.

24. Thank You
For All
• .