Introduction to Emergency Medicine Dr' Tarek Atia

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Introduction to Emergency MedicineDr. Tarek Atia
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• Book The new manual of basic emergency
  procedures Firs aid and updated CPR
• By Professor Mohamed A. Seraj
• 2nd edition

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Subspecialty of Emergency Medicine

• Pediatric Emergency Medicine
• Toxicology
• Sports Medicine
• Undersea and Hyperbaric Medicine

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Challenges to Emergency Medicine

• Interaction with difficult, intoxicated, or
  violent patients or family members
• Work in a fishbowl without 20/20 hindsight
• Finding follow-up or care for uninsured
• Limited resources
• High stress

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Scope to emergency medicine

• What make case emergency
• If acute
• Life threatening
• Chance of permanent morbidity.

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• Asking question
• I) Multiple casualty
• Within capability of the hospital.
• Take patient with most serious situation.
• II) Mass casualty
• Beyond capability of the hospital.
• Disaster
• Take patient with least serious case .i.e the
  least intervention.
• Clean the hospital.

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The golden hour

• Expression that time after the accident is of the
  highest value.
• Because there is high chance to reverse the
  situation.
• THE EARLIER THE BETTER.

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• So, there are two types of care
• I) Pre-hospital care
• Consist of two types of supports
• 1)Basic life support
• Without intervention.
• 2)Advanced life support.
• Like intubations, Intra Venous line.
• With intervention.
• Very useful in cardiac patient.
• Harmful in trauma patient. Because this take the
  golden hour waiting for the ambulance.

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• II)Hospital care
• Behavior and treatment different between
  Emergency Room and word.
• Because in ER there is no time (deal with the
  core of the problem).

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• Approach to ER pt
• History
• Allergy
• Medication
• Past illness/pregnancy. SMPLE Hx
• Last meal.
• Event/ environment.

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• Primary survey
• Airway
• Breathing
• Circulation ABCDE STEP BY STEP
• Disability (CNS).
• Exposure/ Environment expose pt totally. Then
  cover with the blanket.

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• Investigation
• ECG monitoring.
• Urinary and gastric catheter v-important. Good
  urinary out put means proper fluid infusion.
• Monitoring.
• X-ray vital x-ray only. (Pelvis, chest,
  cervical).
• Diagnostic studies.

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• - Secondary survey full history and exam and
  investigation.
• Tertiary survey must be seen by consultant next
  morning.
• - Re-evaluation.
• Definitive care refer him to specialist.

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• Dont forget
• Records.
• Consent for treatment.
• Forensic evidence. (Bullet, knife, clothes).
• Assume pt has cervical injury.
• Finally dont be panic

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ANATOMY AND PHYSIOLOGY OF THE CARDIOVASCULAR
SYSTEM
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ANATOMY OF THE CARDIOVASCULAR SYSTEM

• - It is composed of
• The Heart
• The blood vessels
• Arteries
• Capillaries
• Veins

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THE HEART

• Fist-sized organ situated in the center of the
  chest, between the sternum and the spine and
  above the diaphragm.
• It is surrounded by the lungs except in small
  area in front of the heart known as the bare area
  and the area against the spine.

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• - It has a hollow tough muscular wall
• surrounded by the pericardium.
• - It is divided into right and left side and each
  side has 2 chambers, right atrium and ventricle
  and left atrium and ventricle.

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THE VASCULAR SYSTEM

• It comprises
• Ateries
• Thick-walled, carrying blood from the heart
  under high pressure.
• Capillaries
• Thin network of one cell layer.
• Veins
• Thin-walled vessels that carry blood under low
  pressure back to the heart.

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Pulmonary Circulation
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Pulmonary Circulation
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Systemic Circulation
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Aorta and Major Arteries
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Arteries of the Head and Neck
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Arteries of the Brain
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PHYSIOLOGY OF THE HEART

• 1- Heart pumps blood from the rt. ventricle into
  the pulmonary artery to the lungs to purify the
  blood and from the left ventricle into the aorta
  to distribute blood to the rest of the body.
• 2- Arteries carry blood away from the heart
• 3- veins carry blood back to the heart
• 4- Exchange of gases takes place in the capillary
  system throughout the body.

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Functions

• To purify the blood through the pulmonary
  capillary system
• To provide oxygenated blood to all tissues,
  through the systemic capillary system.

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• The heart beats 60-80 beats per minute during
  rest. The amount of blood pumped by a single beat
  and known as the stroke volume is 70ml.
• The heart pumps 5 lit/min.Cardiac output is
  equal to stroke volume multiplied by heart
  beats/min. That is to say 70x704900 (5
  liters/min).
• The heart can beat faster, up to 180-200
  beats/min during exercise, so it is capable of
  pumping up to 35 lit. per minute.

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Blood supply to the Myocardium

• Two coronary arteries, right and left, originate
  from the first part of the aorta.
• They are divided into several branches which
  encircles the heart to supply the myocardium.
• The coronary arteries are end arteries. There is
  no venous coronary artery.

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Extrinsic Innervation of the Heart

• The heart is stimulated by the sympathetic
  cardioacceleratory center
• The heart is inhibited by the parasympathetic
  cardioinhibitory center

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Conduction system of the Heart

• The contraction is known as systole and is
  followed by a relaxation period known as
  diastole.
• During systole the heart pump blood into the
  vascular system, while during diastole the heart
  is relaxed and receives venous return and
  recharges to prepare for the next beat.

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Electrocardiography (ECG)
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Cardiac Cycle

• Cardiac cycle refers to all events associated
  with blood flow through the heart
• Systole contraction of heart muscle
• Diastole relaxation of heart muscle

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Phases of the Cardiac Cycle

• Ventricular filling mid-to-late diastole
• Heart blood pressure is low as blood enters atria
  and flows into ventricles.
• AV valves are open, then atrial systole occurs.

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Phases of the Cardiac Cycle

• Ventricular systole
• Atria relax
• Rising ventricular pressure results in closing of
  AV valves
• Isovolumetric contraction phase
• Ventricular ejection phase opens semilunar valves

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Phases of the Cardiac Cycle

• Isovolumetric relaxation early diastole
• Ventricles relax
• Back-flow of blood in aorta and pulmonary trunk
  closes semilunar valves
• Dicrotic notch brief rise in aortic pressure
  caused by backflow of blood rebounding off
  semilunar valves.

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Phases of the Cardiac Cycle
Figure 17.18a
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Phases of the Cardiac Cycle
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Heart Sounds

• Heart sounds (lub-dup) are associated with
  closing of heart valves

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At Rest

• Heart beat/minute 70x1
  70
• Heart beat/hour 70x60
  4,200
• Heart beat/day 4200x24
  100,800
• Heart beat/year 100,800x365
  36,792,00
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• Volume pumped/min
  5lit
• Volume pumped/hour 5x60
  300 lit
• Volume pumped/day 300x24
  7200 lit
• Volume pumped/year 7200x365 lit
  2,628,000lit

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THE RESPIRATORY SYSTEM
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• The respiratory system has 4 components
• The Airway
• The neuromuscular system 
• The Alveoli 
• The vascular system, arteries, capillaries veins

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1. THE AIRWAY

• Upper airway
• -Nose and mouth
• -Pharynx
• -Larynx
• Lower airway
• -Trachea
• -Bronchi (right and left)
• -Bronchioles

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2. NEUROMUSCULAR SYSTEM

• Comprises of
• Respiratory centre in the brain
• Nerves
• Muscles of respiration
• These are
• Diaphragm
• Intercostal muscles
• Some muscles in the neck and shoulder girdle
• Chest cage protects the lungs and the heart
• Spine at the back
• Sternum in front
• ribs around

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A- Respiratory centre in the brain Nerves
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Muscles of respiration
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Chest cage
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Chest cage
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3. THE ALVEOLI

• Minute air sacs, millions in number. They are
  made of a very delicate thin membrane of one cell
  layer forming a fine network. The capillaries are
  on the outer side of the alveoli where exchange
  of gases is carried out.

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4. PULMONARY VESSELS

• Arteries carry dark blood with low oxygen levels
  from the heart to the fine network of capillaries
  where O2 is picked-up by the blood and CO2 is
  expelled in to the alveoli. The oxygenated blood
  is the carried out to the left side of the heart
  by the veins.

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PHYSIOLOGY OF RESPIRATION

• The function of the respiratory system is to
  pick-up oxygen from the air and expel carbon
  dioxide into the air. Metabolism is a continuous
  process which needs oxygen to function and as a
  result of this process, carbon dioxide is
  produced. The Cardiovascular system transports
  oxygen from the lungs to the cells and transports
  carbon dioxide from the cells to the lungs for
  elimination.

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• The breathing mechanism is controlled and
  influenced by the respiratory centre in the brain
  and primarily the rate and depth of breathing is
  stimulated by carbon dioxide in the arterial
  blood. As the level rises, the respiratory centre
  sends a continuous parade of signals via the
  nerves to respiratory muscles.

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• This will result in an increasing rate and depth
  of breathing until the level of carbon dioxide
  falls, then the breathing rate and depth are
  returned to normal. This is known as feedback
  mechanism between carbon dioxide level and the
  rate and depth of breathing.

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• During respiration, 5 of oxygen passes from
  atmospheric air into the blood through alveolar
  and capillary walls and 4 of carbon dioxide is
  eliminated from the blood into the expired air.
  Inspiration is an active process while expiration
  is a passive process.