EMERGENCY MEDICINE...pptx Medical students lecturer

Medical students lecturer
Medical students lecturer

1. EMERGENCY MEDICINE Dr. Adenwali Hassan Ahmed: ( Mwn , Medical Doctor, Public Health Officer, Msc-Gyn / Obest .

2. Table of Contents Resuscitation: The act of reviving a person and returning them to consciousness. Airway Breathing Circulation Trauma

3. Resuscitation Airway Decision to Intubate :- Failure to maintain or protect airway (e.g. low GCS, airway trauma) Failure to ventilate/oxygenate (e.g. low or declining oxygen saturation (SpO2), rising partial pressure (pCO2) ) Anticipatory (e.g. trauma, overdose, inhalation injury, anaphylaxis, include Work of breathing (WOB) is the energy expended to inhale and exhale a breathing gas.

4. Assessment Difficult Bag-Valve Mask Ventilation “BOOTS” B = Beard O = Obese O = Older T = Toothless S = Snores/ Stridor Bag-Valve Mask

5. BVM Bag-valve-mask  (BVM) ventilation is an essential emergency skill. This basic airway management technique allows for oxygenation and ventilation of patients until a more definitive airway can be established and in cases where endotracheal intubation or other definitive control of the airway is not possible.

6. Cont--- Difficult Intubation: Look for gestalt signs. Evaluate the 3-3-2 rule. Check for signs of: Obstruction Swelling Trauma. Assess neck mobility.

7. Cont---- Evaluate the 3-3-2 rule: This aspect of airway education involves three measurements — the distance between the upper and lower incisors, the distance between the hyoid bone and the chin and the distance from the thyroid cartilage to the floor of the mouth.

8. Evaluate the 3-3-2 rule:

9. Cont---- Upper lip bite test: Concern if patient cannot bite past vermillion border. Simple New Test for Difficult Airway  

10. Cont--- Difficult Supraglottic Device “RODS” R = Restricted mouth opening O = Obstruction/Obese D = Disrupted or Distorted anatomy S = Stiff lung or cervical Spine.

11. Supraglottic Device Supraglottic Airways: Use in Cardiac Arrest Emergency Medica

12. Airway Techniques Temporizing Measures: Chin lift/jaw thrust Bag-valve-mask (BVM) Suctioning Nasal airway, oral airway, LMA

13. Cont--- Definitive Airway: Orotracheal / Nasotracheal intubation Surgical airway ( percutaneous or open Cricothyrotomy )

14. Cont---- Airway Methods: Rapid Sequence Intubation (RSI) Awake oral intubation Oral intubation without any agents ( ie . “crash” airway) The "crash" airway, in which the patient is in an arrest situation, unconscious and apneic : In this scenario, the patient is already unconscious and may be flaccid; further, no time is available for preoxygenation , pretreatment, or induction and paralysis.

15. Cont---- Rescue Airways: LMA (Laryngeal mask airways are supraglottic airway devices) Cricothyroidotomy

16. Laryngeal mask airways (LMA) are supraglottic airway devices. They may be used as a temporary method to maintain an open airway during the administration of anesthesia or as an immediate life-saving measure in a patient with a difficult or failed airway. Cricothyrotomy (also called cricothyroidotomy ) is a procedure that involves placing a tube through an incision in the  cricothyroid membrane (CTM) to establish an airway for oxygenation and ventilation

17. Rapid Sequence Intubation (6Ps) As a basis for discussion, it has been suggested that the algorithm of RSI consist of six primary steps:  Pre-oxygenation, Premedication , Induction and Muscle relaxation , Intubation , primary and secondary confirmation and post-intubation patient management. A precise rule (or set of rules) specifying how to solve some problem

18. Rapid Sequence Intubation (6Ps) Preparation: Prepare equipment and medications, use checklist if available. Pre-Oxygenation: 100% FiO2, employ PEEP valve to improve recruitment. Fraction of inspired oxygen: Mechanical ventilation

19. Cont--- Pre-Treatment (Optional) Increased ICP: Fentanyl 3mcg/kg Hypotension: Fluids/ vasopressors (infusion or push-dose) Acidosis: Bicarb (controversial), consider maintaining spontaneous respiration Anxiolysis : Midazolam 2-4mg. Fentanyl : a narcotic analgesic that can be inhaled and that acts on the central nervous system

20. Cont--- Positioning Sniffing position, Ramped position if obese, adjust bed height

21. Cont--- Paralysis with Induction: Administration of sedative (i.e. Ketamine , Propofol , Etomidate ) followed by muscle relaxant if indicated (i.e. Succinylcholine 200mg/10ml or Rocuronium ) Rocuronium is a non-depolarizing neuromuscular blocker widely used to produce muscle relaxation to help facilitate surgery and ventilation of the lungs in elective and emergent situations.

22. Cont--- Place Tube with Proof Intubate patient and confirm tube placement (continuous wave form EtCO2). Understand how monitoring end-tidal carbon dioxide helps assess and treat a patient in respiratory distress. Normal EtCO2 levels range from 30s and 40s, but this may vary based on the patient's underlying respiratory and metabolic status. EtCO2 levels that rise from a normal baseline to or above 50 may indicate hypoventilation is occurring.

23. Cont--- Post-Intubation Management Post-intubation analgesia Ongoing sedation Ventilator management Further resuscitation.

24. Equipment Rapid Sequence Intubation Endotracheal tube with an inflatable cuff with sterile lubricant. Laryngoscope handle and blades. Suction x2. Bag valve mask End-tidal carbon dioxide monitor Induction agents Tracheal tube inducer ( bougie ) Supraglottic airway such as laryngeal mask airway. Video-assisted laryngoscopy Pulse oximetry IV access Push dose Pressors

25. Breathing Definitions Acute respiratory failure = pO2 <50mmHg +/- pCO2 >45mmHg Hypoxic Respiratory Failure Diffusion problem: Pneumonia ARDS The distinguishing characteristic of Type 1 respiratory failure is a partial pressure of oxygen (PaO2) < 60 mmHg with a normal or decreased partial pressure of carbon dioxide (PaCO2); 

26. Cont--- V/Q mismatch: Pulmonary embolism (PE), Asthma, COPD Shunt Low ambient FiO2: high altitude Alveolar hypoventilation Hypercarbic Respiratory Failure, Normal Lungs Ventilation-perfusion (V/Q) mismatch occurs when either the ventilation (airflow) or perfusion (blood flow) in the lungs is impaired, preventing the lungs from optimally delivering oxygen to the blood. FiO2: Fraction of inspired oxygen: Mechanical ventilation

27. Cont--- Disorder of respiratory control: Overdose Brainstem lesion CNS disease

28. Cont--- Neuromuscular disorders: Muscular dystrophy Guillain Barre Syndrom ( A rare condition in which a person's immune system attacks the peripheral nerves) Myasthenia Gravis A chronic progressive disease characterized by chronic fatigue and muscular weakness (especially in the face and neck); caused by a deficiency of acetylcholine at the neuromuscular junctions

29. Cont--- Anatomic: Trauma Kyphosis (An abnormal backward curve to the vertebral column) severe scoliosis (spinal curvature) Ankylosing spondylitis : A chronic form of spondylitis primarily in males and marked by impaired mobility of the spine; sometimes leads to ankylosis (Abnormal adhesion and rigidity of the bones of a joint) Inflammation of a spinal joint; characterized by pain and stiffness.

30. Cont--- Hypercarbic Respiratory Failure, Abnormal Lungs Increased airway resistance: Acute exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD), asthma exacerbation Decreased gas exchange: Scarring, Idiopathic Pulmonary Fibrosis (IPF) It is a d/se causes scarring (fibrosis) of the lungs

31. Assessment Look Mental status Color Chest wall movement Accessory muscle use Paradoxical abdominal movement. Paradoxical breathing is typically a symptom of diaphragmatic dysfunction. It has many different potential underlying causes, including nerve disorders, trauma, and infection. The condition can usually be treated when the underlying cause goes away

32. Cont--- Listen Auscultate for breath sounds Signs of obstruction Air entering or escaping Wheeze and stridor

33. Cont--- Feel Tracheal deviation Crepitus - describes a popping, clicking or crackling sound in a joint Flail segments- A flail segment of the chest wall will negatively affect respiration in three ways: ineffective ventilation, pulmonary contusion and hypoventilation with atelectasis . Chest wounds

34. Investigations Labs: CBC, Electrolytes, Cardiac enzymes, BNP Tests: POCUS, CXR +/- CT Chest Brain natriuretic peptide (BNP) test is a blood test that measures levels of a protein called BNP that is made by your heart and blood vessels. BNP levels are higher than normal when you have heart failure. In Point of care ultrasonography (POCUS) is advanced diagnostic ultrasonography that is performed and interpreted by the attending physician as a bedside test. POCUS has been widely used in many disciplines as a rapid diagnostic tool, especially in emergency medicine

35. Management of Breathing Spontaneously Breathing Patient Nasal prongs Face mask, Non- rebreather face mask High flow nasal oxygenation.

36. Face mask, Non- rebreather face mask High flow nasal oxygenation ( ie . MaxTech ) A non- rebreather mask is an oxygen mask that delivers high concentrations of oxygen. It's for when a person needs oxygen quickly in emergencies like injury, smoke inhalation or carbon monoxide poisoning.

37. Cont---- Temporizing Measures for Inadequate Ventilation Bag-valve mask +/- Nasal airway CPAP/ BiPAP : Acute exacerbations of Congestive Heart Failure (CHF), COPD, Asthma Continuous positive airway pressure (CPAP),  bilevel positive airway pressure ( BiPAP )

38. Cont--- Definitive Measures for Inability to Maintain/Protect Airway Oro-tracheal intubation Surgical airway

39. Cont--- Additional Modalities Needle or finger thoracostomy for tension pneumothorax Chest tube to drain- Pleural effusion Hemothorax Pneumothorax

40. Circulation Causes of Shock Hypovolemic Shock Hemorrhage GI losses Third spacing: the accumulation of fluid from the blood within body cavities Dehydration Over diuresis

41. Causes of Shock Cont--- Obstructive Shock (Intra-Thoracic) Shock caused by obstruction of blood flow Pulmonary embolism Cardiac tamponade Tension pneumothorax Valvular dysfunction Congenital heart disease Air embolism

42. Causes of Shock Cont--- Distributive Shock : ( Vasodilation ) Shock caused by poor distribution of the blood flow Septic shock Anaphylactic shock Neurogenic shock Drug overdose Adrenal crisis

43. Causes of Shock Cont--- Cardiogenic Shock : Shock caused by cardiac arrest ACS (Acute coronary syndrome) Cardiomyopathy Cardiac structural damage Dysrhythmias (an abnormal or irregular heartbeat.)

44. Clinical symptoms and signs suggestive of shock Vitals : ­ HR, ¯ BP, ­ RR High initial lactate Urine Output <0.5mL/kg/hr Skin mottling Capillary refill time > 3secs Altered mental status A salt or ester of lactic acid

45. Investigations Labs: CBC Electrolytes BUN Tests: CXR ECG A blood urea nitrogen

46. Management Perfusion Goals Urine Output >0.5mL/kg/h, MAP >65mmHg, Improved mentation Improved cap refill time MAP: Is 65 a good mean arterial pressure?

47. Cont--- Hemorrhagic Hypovolemic Shock: fill the tank Control hemorrhage (tourniquets, Direct compression, Pelvic binders). Fluids until blood available Blood product transfusion.

48. Cont--- Obstructive Shock: alleviate obstruction Tension pneumothorax : needle decompression then chest tube. Cardiac tamponade : IV crystalloids, pericardiocentesis ( Pericardiocentesis is a procedure performed to remove pericardial fluid from the pericardial sac) Crystalloid fluids are a subset of intravenous solutions that are frequently used in the clinical setting. Crystalloid fluids are the first choice for fluid resuscitation in the presence of hypovolemia , hemorrhage, sepsis, and dehydration. Crystalloid solutions, which contain water-soluble electrolytes including sodium and chloride

49. Cont--- Pulmonary embolism: IV crystalloid, inotropes , thrombolysis

50. Cont--- Distributive Shock: ( vasodilatory shock) S ource control, squeeze the pipes Anaphylaxis: Epinephrine IM, IV crystalloids, Antihistamines, Corticosteroids Sepsis: Broad-spectrum antibiotics, IV crystalloids +/- norepinephrine . An intra-aortic balloon pump (IABP) is a type of therapeutic device. It helps your heart pump more blood.

51. Cont--- Cardiogenic Shock: S upport forward flow Norepinephrine 5mcg/min, Dobutamine 2.5 mcg/kg/min. Dobutamine is a medication used in the ICU to manage low blood pressure. Norepinephrine  ( Levophed ) is indicated for blood pressure control in certain acute hypotensive

52. Cont--- Treat underlying cause: Cath lab, Mechanical circulatory support (IABP, Impella , Ventricular assist device (VAD), ECMO), Heart transplant. ECMO: Extracorporeal membrane oxygenation IABP: An intra-aortic balloon pump (IABP) is a type of therapeutic device. It helps your heart pump more blood. Cath lab: Catheterization laboratory Impella is a family of medical devices used for temporary ventricular support in patients with depressed heart function. Impella

53. Cont--- Cellular Toxins Antidotes for various toxins. A remedy that stops or controls the effects of a poison An antidote is a drug, chelating substance, or a chemical that counteracts (neutralizes) the effects of another drug or a poison.

54. ASSIGNMENT? Impella The Impella  pulls blood from the ventricle and pushes it out into the aorta, delivering oxygen-rich blood to the rest of your body. This allows your heart to rest while the doctor performs the PCI. Once the PCI procedure is complete, the Impella is turned off and guided out

55. IABP: An intra-aortic balloon pump  (IABP) is a type of therapeutic device. It helps your heart pump more blood. Impella : The Impella  pulls blood from the ventricle and pushes it out into the aorta, delivering oxygen-rich blood to the rest of your body. This allows your heart to rest while the doctor performs the PCI. Once the PCI procedure is complete, the Impella is turned off and guided out. VAD: A  ventricular assist device  ( VAD ) is a device that helps pump blood from the lower chambers of the heart to the rest of the body.

56. ECMO: Extracorporeal membrane oxygenation (ECMO) is a form of life support used for babies, children and adults with life-threatening heart and or lung problems. ECMO provides time for the body to rest and recover by doing the work of the heart and lungs.

57. Trauma Resuscitation Primary Survey 1. Airway Assess patency of airway Look for obstruction (blood, emesis, teeth, foreign body) Ensure C-spine precautions Airway management. Patency ( open )

58. Cont--- 2. Breathing Expose chest Assess breathing Auscultate for breath sounds Rule out tension pneumothorax . LOC: Level of consciousness

59. Cont--- 3. Circulation Assess LOC: Level of consciousness Signs of shock (HR, BP, skin color, urine output, base deficits) Sources of bleeding (external, chest, abdomen, pelvis, femur). LOC: Level of consciousness

60. Cont--- 4. Disability GCS assessment Neurological evaluation

61. Cont--- 5. Exposure/Environment Fully expose patient, logroll patient to inspect for injuries, spine tenderness and rectal exam for high-riding prostate and tone Keep patient warm and dry to prevent hypothermia

62. Cont--- Adjuncts (multiple added) eFAST Exam: subxiphoid pericardial window, perisplenic , hepatorenal , Pelvic/ retrovesical , bilateral anterior lung. Portable X-ray: chest, pelvis, grossly deformed limbs ECG: Evaluate for dysrhythmias E-FAST (Extended Focused Assessment with Sonography in Trauma) is a bedside ultrasonographic protocol designed to detect peritoneal fluid, pericardial fluid, pneumothorax , and/or hemothorax in a trauma patient

63. Investigations Blood work: CBC Lytes BUN (Blood Urea Nitrogen), Glucose, Lactate, INR/PTT, Fibrinogen, B- hCG , U/A Partial thromboplastin time (PTT) The international normalised ratio (INR) blood test tells you how long it takes for your blood to clot.

64. Cont--- Imaging: CT (selective vs. pan-scan) - for stable patients; Unstable patients may require emergent OR

65. Cont--- Trauma Triad of Death Coagulopathy Hypothermia Acidosis

66. Management General Resuscitation Immediate hemorrhage control (Stop the Bleed) Blood transfusion: balanced resuscitation to avoid dilutional coagulopathy Tranexamic acid: 1g IV over 10 minutes then 1g IV over 8 hours Consider permissive hypotension Permissive hypotension is the act of maintaining a blood pressure lower than physiologic levels in a patient that has suffered from hemorrhagic blood loss.

67. Cont--- Head Trauma Seizure management/prophylaxis, treat suspected raised ICP, Neurosurgical intervention for severe head injury/bleeds.

68. Cont--- Spinal Cord Trauma Complete immobilization Treat neurogenic shock Consult spine service.

69. Cont--- Chest Trauma Airway management Bedside resuscitative thoracotomy in arrest, Surgery for life-threatening lung, Diaphragmatic, Esophageal, aortic, Myocardial injuries.

70. Cont--- Abdominal Trauma Laparotomy for hemodynamically unstable and hollow organ injuries.

71. Cont--- Orthopedic Injuries Reduce and immobilize when possible Irrigate open fractures Assess for neurovascular and skin compromise Adequate analgesia Consult orthopedic Orthopedics: The branch of medical science concerned with disorders or deformities of the spine and joints

72. END END