Lecture Title: General objectives of the emergency room management Lecturer name: Dr. Hossam Hassan Lecture Date:

Lecture Objectives..Students at the end of the lecture will be able to: Recognize and be aware of the basic management of common BLS and ACLS protocols. Gain experience in the evaluation and management of patients presenting to the ER for acute care. Developing proficiency with emergency procedures Expanding the knowledge in acute care medicine to include , Acute Chest pain, Trauma ,and shock management..

Objectives Acute medical illnesses Acute surgical illnesses Acute Obstetrical emergencies Trauma Acute mental illnesses Acute ENT & Ophthalmological emergencies Environmental hazards

Top Ten Leading Causes of Death Heart Disease: 726,974 Cancer: 539,577 Stroke: 159,791 Chronic Obstructive Pulmonary Disease: 109,029 Accidents: 95,644 Pneumonia/Influenza: 86,449 Diabetes: 62,636 Suicide: 30,535 Nephritis, Nephrotic Syndrome, and Nephrosis 25,331 Chronic Liver Disease and Cirrhosis: 25,175

Reception 300 – 500 visits per day Only 20-50 cases require urgent intervention Few cases are life-threatening (1-5)

Triage

Triage ( Categorization) Category 1 – 5 1 : Life-Threatening 5 : Triage out

Triage Physician Triage Nurse Triage Clark Triage

Life-Threatening Cases ( C.1) Need immediate intervention Arrest Arrhythmias Hypoxia Shock Acute trauma Siezure Status Asthmaticus Anaphylaxis Chest pain ( STEMI ) Delivery – stage 2

C.2 ( Urgent Cases) Should be treated within 10 min. Acute asthmatic attack High Blood Pressure Intoxication Drowsy patient Acute colics Fractures Burns

C.3 ( Acute Cases ) Should be treated within 30 minutes Chest Pain ( Non cardiac ) Abdominal pain Dyspnea Fever Old trauma Gastroeneteritis Metabolic Derangement Post ictal state

Cont’d Triage C4 : Chronic Abdo pain Minor trauma claimed : Fever-Low BP- Fast HR C5 : URTI Long-standing complaints Meds-Refill

Appeal of Emergency Medicine Make an immediate difference Life threatening injuries and illnesses Undifferentiated patient population Challenge of “anything” coming in Emergency / invasive procedures Safety net of healthcare There is no better job than emergency medicine. We work as the detective to determine the cause of the patients complaints. Patients are not admitted to us with pyelonephritis. They present with an undifferentiated complaint such as back pain and fever. We have to investigate the complaint through history and physical exam, as well as labs and radiographs. We have to work through a very large differential. We see anybody and everybody. We have the chance to make the difference in somebody’s health almost every day. We must be prepared to take care of any emergency that arrives at the ED.

Appeal of Emergency Medicine Team approach Patient advocacy Open job market Academic opportunities Shift work / set hours Evolving specialty Within EM, we work through a team approach with other specialties to arrive at an appropriate diagnosis and treatment plan for the patient. We must stand firm on what is best for the patient even if our consultants would rather not admit them. We work set hours which allows us to better plan our lives. It allows us more time for our families or interests. We know where our work day ends and our private lives begin. The opportunities within academics are huge. You can work in any setting from a community hospital to a level 1 intercity trauma center. Emergency medicine will continue to grow in the future. There are many avenues that we can improve upon and develop.

Downside to Emergency Medicine Interaction with difficult, intoxicated, or violent patients Finding follow-up or care for uninsured Working as a patient advocate Contract management groups Malpractice targets At times, dealing with consultants can be difficult. This is due to the personality of that particular consultant, not the specific specialty. Some patients are under the influence of drugs that cause them to be violent or inappropriate. This should be looked upon as a challenge, not a problem Many patients arrive at the ED without any emergency. Instead they arrive because of convenience for either them or their physician. Although frustrating, it still allows you to practice medicine. There will be times when other specialists look back at your care and determine that it was inappropriate now that they have much more information. Always do the right thing based on what information you have available.

The Lifestyle:Two Sides of A Coin Well defined shifts Usually not on call Part time employment possible Evenings and nights Weekends Holidays Many physicians migrate to EM due to the hours and well defined shifts. However, this must be balanced against the evenings and nights that are part of the career.

Subspecialties in Emergency Medicine Pediatric Emergency Medicine Toxicology Emergency Medical Services Sports Medicine Critical Care Medicine One can move onto various areas of sub-specialty from the specialty of Emergency Medicine. These are the four areas in which we can become board certified through fellowship training.

Upcoming Areas of Emergency Medicine Observation units ED CT The future of EM is limitless. We are branching out into various areas of medicine to include these.

Research Opportunities Broad range of subjects Limited amount of work published in our relatively new field Limited number of research mentors Limited number of clinical trials Research within EM is not yet well established. However, it is limitless. You can pick almost any area of medicine and research it from the emergency department standpoint. As the specialty grows, there are more and more competent and qualified researchers promoting EM. The number of research projects and clinical trials will continue to grow.

What to do to get in to Emergency Medicine ? Observe in ED Summer research projects with EM staff EM interest group affiliation Be open to any medical specialty In order to become more familiar with the field of EM, first and second year students can do many things. Take time to do “shadow shifts” in the ED to see what actually happens. It is not the same as the “ER” television show. Join the EM interest group if you like the field of emergency medicine. It will help you locate others with similar interests and will allow you more time with the EM faculty. At this time in your medical school career, always keep your options open. Look at all areas of medicine before you lock yourself into one area. Take this time to openly investigate any area that interests you.

Trauma

Primary Survey ( A-B-C-D)

Secondary Survey ( Systemic)

What’s Your Diagnosis ?

OR

Chest pain ( Cardiac )

Chest Pain

Arrhythmias

Low Blood Pressure PB = COP * SVR ( 120 / 80 ) mmHg COP = SV * HR ( 4- 6 ) 4-6 L/m SV = EDV - ESV ( 50 – 100 ) ml

Low Blood Pressure Preload Contractility Afterload

Dyspnea ( S.O.B) ABG : 7.35 40 80 23 O2 saturation: 99%

Acute Respiratory Failure Hypoxemic Hypercapnic

Asthma

COPD

Pneumonia

Abdominal Pain ( Medical )

Abdominal Pain ( Surgical )

Fractures

Fractures

Fractures

Laceration

Seizure

Acute Psychiatric Ilnesses

DM

DKA

Skin Rash

Where do you taiage this Pt.? What information do you need to determine if this Pt. is in shock? What initial interventions are needed to stabilize that Pt.?

Shock is a syndrome of impaired tissue oxygenation and perfusion due to a variety of etiologies If left untreated Irreversible injury ,Organ dysfunction And finally death

Clinical ulterations in shock The presentation of patients with shock may be Subtle(mild confusion,tachycardia) Or easily identifiable(profound hypotesion.anuria)

The clinical manifestation of shock result from 1- inadequate tissue perfusion and oxygenation 2- Compansatory respnses 3- The specific etiology

Clasification of shock 1-hypovolemic a-Hemorrhagic b-nonhemorrhagic 2-Cardiogenic Ischemic Myopathy Mechanical Arrhythmia

3- Distributive Septic Adrenal crises Neurogenic (spinal shock) Anaphylactic

4- Obstructive Massive Pulmonary embolism Tension pneumothorax Cardiac tamponade Constrictive pericarditis

HYPOVOLEMIC SHOCK It occure when the intra vascular volume is depleted relative to the vascular capacity as a result of 1- Hge. 2- G.I.T loss 3-urinary loss 4-dehydration

HYPOVOLEMIC SHOCK Management The goal is to restore the fluid lost Vasopressors are used only as a temporary method to restore B.P untill fluid resuscitation take place

Distributive shock It is characterized by loss of vascular tone The most common form of distributive shock is septic shock The hemodynamic profile of septic shock include

Cardiac output normal or increased Ventricular filing pressure normal or low SVR low Diastolic pressure low Pulse pressure wide

Management of septic shock The initial approach to the patient with septic shock is the restoration and maintenance of adequate intravascular volume Prompt institution of appropriate antibiotic

CARDIOGENIC SHOCK Forward flow of blood is inadequate bec. Of pump failure due to loss of functional myocardium It is the most severe form of heart failure and it is distinguished from chronic heart failure by the presence of hypotension,hypoperfusion and the need for different therapuetic inteventions

Hemodynamic chracteristics Cardiac output low Ventricular filing pressure high SVR High Mixed venous o2 sat low

MANAGEMENT OF CARDIOGENIC SHOCK The main goal is to improve myocardial function Arrhythmia should be treated Reperfusion PCI is the treatment of choice in ACS Inotropes and vasopresor

Obstructive shock Obstruction to the outflow due to impaired cardiac filling and excessive after load Cardiac tamponade and constrictive pericarditis impair diastolic filling of the Rt.ventricle Tension pneumothorax limit Rt.ventricular filing by obstruction of venous return Massive pulmonary embolism increase Rt.ventricular afterload

Hemodynamic profile in obst. Shock Cardiac output low Afterload high Lt.Vent.filling pressure variable Pulsus paradoxicus in Tamponade Distended Jugular viens

Management Of Obstructive Shock Directed Mainly to Management of the cause

GENERAL Principles of shock management The overall goal of shock management is to improve oxygen delivery or utilization in order to prevent cellular and organ injury Effective therapy requires treatment of the underlying etiology

Restoration of adequate perfusion, monitoring and comperhensive supportive care Interventions to restore perfusion center on achieving an adequate B.P, increasing cardiac output and optimizing oxygen content of the blood

Oxygen demand should also be reduced

In Summery Management of shock 1- Monitoring 2- Fluid Therapy 3- Vasoactive agents 4- Treat the cause

Reference book and the relevant page numbers..

Thank You  Dr.