ACCIDENT & EMERGENCY.pptx

For medical knowledge

1. Accident and Emergency

2. Accident Unexpected event, typically sudden in nature and associated with injury, loss, or harm. Accidents are a common feature of the human experience and result in injury or permanent disability to large numbers of people worldwide every year. Many accidents also involve damage to or loss of property. Accidents can occur anywhere, including in the home, during transportation, in the hospital, on the sports field, or in the workplace.

3. Emergency An emergency is an urgent, unexpected, and usually dangerous situation that poses an immediate risk to health, life, property, or environment and requires immediate action .

4. Types of injury Blunt, Penetrating, Blast, Crush and Thermal injury. Blunt injury A direct mechanism : when the damage occurs at or close to the site of impact. An indirect mechanism : when the damage occurs at a distant site after transmission of that force.

5. The most common cause of blunt trauma is the motor vehicle. Factor related to motor vehicles injuries Mass Speed : 10% increase in impact speed translates into a 40% rise in the case fatality risk for occupants.

6. Wearing seatbelts : reduce the risk of death or serious injury for front-seat occupants by approximately 45%, but causes fourfold increase in thoracic trauma and eightfold increase in intra-abdominal trauma. Ejection from a vehicle is associated with a significantly greater incidence of severe injury.

7. Penetrating injury A low-velocity projectile behaves more or less like a stabbing injury. The kinetic energy of stab wounds is low, and death occurs only if a critical organ such as the heart or a major blood vessel is injured. The high-velocity bullet causes motion of the tissue particles away from their original position produces a cavity.

8. Blast injury Bursting of bombs ruptures their casing and imparts a high velocity to the fragments. This is accompanied by a blast pressure wave with mass movement of air, which result in severe devastating injury to the tissues. Injury patterns ranging from injury to the ear, lungs, heart, and total body disruption.

9. Heavy contamination of the soft-tissue wounds with dirt, clothing and secondary missiles such as wood, and other materials from the environment. It is imperative that wounds should be left open and delayed primary closure performed.

10. Crush injury Occurs when the body or part of it is subjected to a high degree of force or pressure, usually after being squeezed between two heavy or immobile objects. Causes lacerations, fractures, bleeding, bruising, compartment syndrome and crush syndrome.

11. Crushing of muscle mass sequesters fluid, so reducing the effective intravascular volume, which results in renal vasoconstriction and ischemia, with release of myoglobin and vasoactive mediators into the circulation. Myoglobin is precipitated in the tubules, leading to tubular obstruction.

12. Intensive care is required with close attention to fluid balance. The patient should be catheterized. Compartment syndrome of a limb may occur. Basic types of trauma Serious and life-threatening injury Significant trauma requiring treatment but not immediately life threatening.

13. Distribution of deaths from trauma with regard to time Immediate- death within the first few minutes, unsalvageable patients, 50% of all deaths. Devastating brain, heart or major vessel injury. Early- within the first few hours, represents 30% of all deaths, often death from torso trauma. Life threatening injuries requiring urgent attention. Deaths occur as a result of hypovolaemia and haemorrhage . Many of these deaths may be preventable.

14. Late- death within days/ weeks, represents 20% of all deaths, resulting from the complications of initial injuries like sepsis or multiple organ failure.

15. Preparation Pre-hospital phase- there must be good coordination and communication pathways set up prior to transfer of the injuried from the scene of injury. In-hospital phase- a resuscitation area should be available and secured. Equipment in this area should be checked daily and placed where it is immediately accessible. Warmed intravenous crystalloid solutions should be prepared and ready for immediate attachment on arrival.

16. The laboratory team should be warned that blood may be urgently needed. Techniques such as “ Damage control resuscitation” and “Damage control surgery” have dramatically improved survival. DAMAGE CONTROL Minimizing surgery until the physiological derangement can be corrected with two goal: (1) Stopping any active surgical bleeding. (2) Controlling any contamination.

17. The operation is then suspended and the abdomen temporarily closed. The patient’s resuscitation continues in the intensive care unit. Once the physiology has been corrected, the patient is returned to operation theatre for definitive surgery.

18. TRIAGE The sorting of patients, with the most severely injured patients being treated first. The sorting of injuries, so that the most compelling threats to life, eg . Bleeding sites, receive priority. Three essential phases: 1. Pre-hospital triage_ in order to dispatch ambulance and pre- hospital care resources.

19. 2. At the scene of trauma. On arrival at the receiving hospital. Triage situation Multiple casualties: The number and severity of injuries do not exceed the ability of the facility to render care. Priority is given to the life threatening injuries followed by those with polytrauma .

20. Mass casualties: The number and security of the injuries exceed the capability and facilities available to the staff. In this situation, those with the greatest chance of survival and the least expenditure of time, equipment and supplies are prioritized.

21. ABC of Trauma care : A: Airway maintenance with cervical spine control B: Breathing and ventilation C: Circulation D: Disaility (neurological status) E: Exposure A: Airway maintenance with cervical spine control Ensure a patent airway while protecting the cervical spine. Airway obstruction produces altered level of consciousness, noisy breathing with undetectable expired air. Consider all MIPs have a cervical spine injury until proved otherwise. Stabilize the neck by fitting a rigid color and tape the forehead to the sides of the trolley.

22. The causes of upper airway obstruction: - Oropharynx- tongue(fallen back), or teeth, dental plates, foreign body, blood and vomit. Head altered level of consciousness after head injury, alcohol and drug. Maxillofacial injuries- fracture of maxilla or mandible. Neck- laryngeal injury. Clear airway initially by chin lift or jaw thrust maneuvers and using a gloved two finger sweep and suction to remove the obstructing cause. May need oropharyngeal or nasopharyngeal airway, cricothyroidotomy or tracheostomy may be needed in cases of crush injuries of the larynx, cricotracheal separation, or perforation/ laceration of the trachea. B – Breathing and ventilation Patient with inadequate ventilation (hypoxia) may be distressed, irritable and cyanosed. A patent airway does not ensure adequate ventilation.

23. Inspection of chest wall may reveal respiration rate and depth, bruising, clothing imprint, open wounds, and unequal movement due to flail segment. Palpation and auscultation may demonstrate surgical emphysema, tension pneumothorax and/or haemothorax , cardiac temponade . Pulse oximeter gives an indication of the adequacy of perfusion and arterial oxygen saturation. Giving 100% oxygen (high concentration oxygen 6-8 liters/min) to every patient through a mask or by intubation if necessary.

24. The following life threatening conditions need immediate treatment Airway obstruction Tension pneumothorax Large(massive) haemothorax Sucking chest wound (open pneumothorax) Flail segment(and underlying lung contusion) Major disruption of the trachea-bronchial tree Cardiac temponade

25. C- circulation with haemorrhage control A rapid assessment of the cardiovascular system should be made from clinical examination including pulse rate (rapid, thread pulses are early signs of hypovolaemia ),blood pressure, skin color, capillary refill, level of consciousness and respiratory rate. Cerebral circulation may be impaired resulting in altered level of consciousness. In a MIP blood loss is the commonest cause of diminished conscious level. External, severe haemorrhage should be identified and controlled by direct manual pressure or applying dressing. Tourniquets should not be used to prevent bleeding from a limb as they occlude collateral circulation causing tissue destruction. Penetrating wounds should be identified and explored by a surgeon.

26. D- disability (neurological status) A rapid assessment of the neurological state can be made by seeing if the patient is speaking, by looking at the pupils and assessing the level of consciousness. A simple mnemonic is AVPU : A; alert V; vocal stimuli response P; painful stimuli response U; Unresponsive The Glasgow Coma Score (GCS) is more comprehensive but is often left until the secondary survey. Mild: GCS 14-15 Moderate: 9-13 Severe: 8 or below

27. E- exposure Fully undress the patient to allow a thorough examination, but keep the patient warm (with caution).

28. Thanks