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

2. 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..

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

4. 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

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

6. Triage

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

8. Triage
Physician Triage
Nurse Triage
Clark Triage

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

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

11. 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

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

13. 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.

14. 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.

15. 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.

16. 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.

17. 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.

18. 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.

19. 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.

20. 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.

21. Trauma

22. Primary Survey ( A-B-C-D)

23. Secondary Survey ( Systemic)

24. What’s Your Diagnosis ?

25. OR

26. Chest pain ( Cardiac )

27. Chest Pain

29. Arrhythmias

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

31. Low Blood Pressure
Preload
Contractility
Afterload

32. Dyspnea ( S.O.B)
ABG : O2 saturation: 99%

34. Acute Respiratory Failure
Hypoxemic
Hypercapnic

35. Asthma

36. COPD

37. Pneumonia

38. Abdominal Pain ( Medical )

39. Abdominal Pain ( Surgical )

40. Fractures

41. Fractures

42. Fractures

43. Laceration

44. Seizure

45. Acute Psychiatric Ilnesses

46. DM

47. DKA

48. Skin Rash

49. 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.?

50. 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

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

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

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

54. 3- Distributive
Septic
Adrenal crises
Neurogenic (spinal shock)
Anaphylactic

55. 4- Obstructive
Massive Pulmonary embolism
Tension pneumothorax
Cardiac tamponade
Constrictive pericarditis

59. 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

60. 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

61. 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

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

63. 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

65. 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

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

67. 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

68. 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

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

70. Management Of Obstructive Shock
Directed Mainly to Management of the cause

71. 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

72. 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

73. Oxygen demand should also be reduced

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

75. Reference book and the relevant page numbers..

76. Thank You 
Dr.