Highly useful for undergraduate medical students while dealing with acute medical emergencies in pre-hospital scenario

1. ADULT MEDICAL EMERGENCIES
Dr. Swarnalingam Thangavelu M.D
Assistant Professor
Department of Anaesthesiology
TMCH

2. OBJECTIVES
 To identify, evaluate and treat the emergency medical conditions in a pre
hospital scenario
 The role of Emergency Medical Services (EMS) in prompt & timely referral
services since,
“Time lost is lives lost”

3. COMMONPRESENTATION-PRE HOSPITAL CARE
Dyspn
ea/
Respir
atory
distres
s
Cardia
c /
Circula
tory
emerge
ncies
Altered
level of
conscio
usness

4. 1.Dyspnea/Respiratory distress
 Most common presenting symptom
 Significant mortality

5. Common causes: Acute shortness of breath(Non-traumatic)
 Exacerbated COPD
 Asthma
 Cardiogenic pulmonary edema(CCF)
 Non cardiogenic pulmonary Edema (Inhalational, sepsis related)
 Pneumonia
 Pulmonary embolism
 Foreign body obstruction
 Aspiration

6.  On the scene-identifying the correct diagnosis
 Not always straight forward
 Since the etiology of dyspnea is multifactorial
 Patient with severe COPD & CCF ( who develops pneumonia)

7. Patient Evaluation
 To identify the condition
 Life threatening with imminent respiratory failure and requires immediate
treatment

8. Signs and symptoms indicating life threatening condition
 Cyanosis
 Bradypnea RR <6/min or Tachypnea >30 breaths/min
 Tachycardia
 Inability to speak in full sentences < 5-6 words
 Use of accessory respiratory muscles

9. Pulse Oximetry
 Use of pulse oximetry in diagnosing hypoxemia (Spo2< 92-94% in room air)
 Objective measurement of the severity of respiratory distress

10. Pre hospital management
A. Bronchospasm: COPD and asthma
 High flow O2 through non-rebreathing mask (irrespective of cause)
 Patient’s medical history
 Currrent medications (inhaled beta2 agonists + corticosteroids in severe case)
 In addition to dyspnea
Wheezing & coughing-classic symptom of bronchospasm
 In extreme bronchospasm

11. Silent Chest

12. TREATMENT
OXYGEN

13.  Inhaled Beta 2 agonists (Nebulised aerosol or MDI)
Albuterol 2.5-5mg every 20 minutes x 3 doses
 + Anti-cholinergics
Ipratropium bromide 0.5mg every 20 minutes x 3
doses
 Iv bolus of Methyl prednisolone 60-125 mg (severe
exacerbation)
 Subcutaneous beta agonists- Adrenaline 0.3-0.5mg
every 20 minutes x 3 doses OR
 Subcutaneous terbutaline 0.25mg every 20 minutesx 3

14. Impending or Acute respiratory arrest
 Endotracheal Intubation
 Rapid sequence induction with ketamine (bronchodilator)

15. Vigilant Monitoring
 Look and monitor for additional conditions (that add to the severity of
hypoxemia)
Pneumonia
Pneumothorax
Anaphylaxis
Pulmonary embolism

16. b. Pulmonary edema
 In addition to standard monitoring
 12 lead ECG is essential to R/O acute MI
 Usage of point of care BNP testing on the scene to determine the cause of
dyspnea (>100pg/ml is diagnostic of cardiogenic cause)

17. Treatment goals
 To stabilize the patient
 Improve oxygenation and perfusion
 Reduce dyspnea
 NIPPV such as CPAP – standard therapy
 Subsequent therapy should be guided by the patient’s systolic BP

18. >140mmHg
NIPPV+ Nitrates
NTG spray or
continuous NTG
infusion
5-20 mcg/min
Systolic BP TREATMENT OPTIONS
100-140mmHg
<100mmHg
NIPPV+
Nitrates+
Diuretics ( if
signs of
systemic fluid
retention)
Predominant
signs
Of Cardiogenic
shock
-Inotropes
Dopamine+
Dobutamine +
fluid challenge

19.  Pulmonary edema with signs of acute coronary syndrome-
Treat like specific ACS – in addition to NIPPV + Nitrates

20. 2.Cardiac & Circulatory emergencies
CHEST PAIN
Circulatory problems
( Syncope, Hypertension)

21.  Much emphasis
 Role of EMS- in the management of STEMI
 Our Focus
Chest pain
Hypertensive Emergencies

22. PATIENT EVALUATION-ACS
 Goal: To R/o life threatening condition such as ACS or PE
 Common complaint: Chest pain
 Identifying high risk group among all patients with
Back spasm
Esophageal acid reflux
GI disorders

23.  History & Physical examination to guide the diagnosis
 12 lead ECG

24.  Assessing the type of pain- stabbing versus burning
 Quality of chest pain
 Radiation, severity and provocation factors
 To determine the differential diagnosis

25. Atypical pain symptoms
 Epigastric discomfort
 Jaw pain
 No pain ( silent MI in diabetic patients)

26. Pre hospital management-ACS
 Continuous ECG monitoring
 BP & Spo2 monitoring
 Rapid access to defibrillation
 Goal:
To reduce myocardial O2 demand while improving O2 supply

27. MONA- Acroynm
 Morphine-pain control Dose: 2-4 mg iv bolus
 Oxygen-high flow O2
 Nitrates- if patient is not hypotensive (caution in RV infarction)
 Aspirin Dose: 162-325 mg (non-enteric coated chewable form)
 Beta blockers- if tachycardic and/or hypertensive
Metoprolol 5 mg iv every 5 minutes x 3 doses

28. PRE -HOSPITAL ECG
 Vital component of pre hospital care
 Only tool –reliably identify the patients who will benefit from prehospital
reperfusion therapy
 Goal: limit myocardial ischemia time <120 minutes (ideally <60 minutes)

29. Early out of hospital fibrinolysis
 Reduces mortality in patients with STEMI
 New onset LBBB
 The recommended standard for fibrinolysis –capable EMS systems

30. Fibrinolytic agents
 Streptokinase
 Recombinant tissue plasminogen activator (rt-PA or t-PA)
 Modified forms of t-PA
Reteplase Dose: 10 U iv bolus and repeat 10 U iv after 30 minutes
Tenecteplase

31. Contraindications
 Risk of ICH ---Major disability or death in 1-2% of patients
 If fibrinolysis is not possible-
 Transport to a facility with PCI with goal of EMS arrival to balloon time <90
minutes since
“Time is muscle”

33. B.PULMONARY EMBOLISM
 Definitive diagnosis –difficult to establish on the scene
 Since the signs & symptoms are non specific
 No rapid objective measures-12 lead ECG in NSTEMI

34.  Medical history
Immobilization
Signs of pre existing DVT (unilateral, tender swelling in one extremity)
 Severity of PE:
Related to the size of clots
Ranges from mild symptom( dyspnea & coughing) to life threatening
states & cardiogenic shock due to acute right sided heart failure

35. Classic symptoms of Pulmonary Embolism
 Distended neck veins
 Hypoxemia
 Tachycardia
 Tachypnea
 Chest pain

36. Non specific findings
 More objective
 New onset RBBB
 Symmetric T inversion in anterior leads V1-V4
 S1 QIII pattern in 12 lead ECG- more useful to R/O MI rather than PE

37. Management
 Largely supportive –absence of objective diagnosis
 High flow O2
 IV line
 Pain control with opioid analgesics
 Hypotension(severe PE) –inotropic agents for circulatory support
 No universal recommendation for pre-hospital usage of heparin
 Determined on a case to case basis
 Successfully used in extremis

38. c.Hypertensive emergencies
 Classificaton of hypertensive episodes
Very useful in determining the urgency of pre hospital intervention
 Acute end organ damage in conjunction with hypertensive episodes
Hypertensive encephalopathy/stroke
Pulmonary edema/MI/Aortic dissection
Acute renal failure
Pre-eclampsia

39. Classification of acute hypertensive episodes (JNC Seventh Report-
2003)
Hypertensive Emergency Also termed hypertensive crisis
Hypertension with acute EOD
Hypertensive Urgency Hypertensive episode with high risk of
imminent EOD that has not yet occurred
Acute hypertensive episode SBP >180mmHg or DBP >110mmHg
Without signs of evolving or imminent
EOD
Transient hypertension Related to anxiety or primary complaint

40. Management
 Must be immediately treated & progression must be stopped
 Goal: To lower BP by 20-25% within 30-60 minutes
 In setting of cerebral infarction
Great care in reducing BP
Since the ischemic territory –critically dependent on collateral
perfusion pressure
 Evidence for benefits of anti-HT treatment is scant
 Some – only excessively high SBP or DBP should be treated
 Patients with aortic dissection-require swift and aggressive treatment with a
target BP
SBP <120mmHg or DBP< 80 mmHg

41. Treatment
 Choice of anti-hypertensive – underlying pathophysiology
 Hypertension + ACS + Tachycardia- Beta blockers & NTG
 ICH – Labetalol –preferred agent Dose: 20mg iv over 2 minutes & repeat every
10 minutes @ dosage of 20-40mg
 European EMS system- Urapidil ( alpha – adrenoreceptor antagonist)

43. THANK YOU