Lecturer name: Dr. Hossam Hassan

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

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Objectives

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

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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

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Reception

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

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Triage
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Triage ( Categorization)

• Category 1 5
• 1 Life-Threatening
• 5 Triage out

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Triage

• Physician Triage
• Nurse Triage
• Clark Triage

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Life-Threatening Cases ( C.1)

• Need immediate intervention
• Arrest
• Arrhythmias
• Hypoxia
• Shock
• Acute trauma
• Siezure
• Status Asthmaticus
• Anaphylaxis
• Chest pain ( STEMI )
• Delivery stage 2

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C.2 ( Urgent Cases)

• Should be treated within 10 min.
• Acute asthmatic attack
• High Blood Pressure
• Intoxication
• Drowsy patient
• Acute colics
• Fractures
• Burns

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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

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Contd Triage

• C4 Chronic Abdo pain
• Minor trauma
• claimed Fever-Low BP- Fast HR
• C5 URTI
• Long-standing complaints
• Meds-Refill

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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

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Appeal of Emergency Medicine

• Team approach
• Patient advocacy
• Open job market
• Academic opportunities
• Shift work / set hours
• Evolving specialty

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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

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The LifestyleTwo Sides of A Coin

• Well defined shifts
• Usually not on call
• Part time employment possible
• Evenings and nights
• Weekends
• Holidays

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Subspecialties in Emergency Medicine

• Pediatric Emergency Medicine
• Toxicology
• Emergency Medical Services
• Sports Medicine
• Critical Care Medicine

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Upcoming Areas of Emergency Medicine

• Observation units
• ED CT

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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

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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

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Trauma
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Primary Survey ( A-B-C-D)
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Secondary Survey ( Systemic)
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Whats Your Diagnosis ?
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OR
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Chest pain ( Cardiac )
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Chest Pain
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Arrhythmias
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Low Blood Pressure

• PB COP SVR ( 120 / 80 ) mmHg
• COP SV HR ( 4- 6 ) 4-6 L/m
• SV EDV - ESV ( 50 100 ) ml

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Low Blood Pressure

• Preload
• Contractility
• Afterload

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Dyspnea ( S.O.B)

• ABG 7.35
• 40
• 80
• 23
• O2 saturation 99

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Acute Respiratory Failure

• Hypoxemic
• Hypercapnic

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Asthma
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COPD
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Pneumonia
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Abdominal Pain ( Medical )
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Abdominal Pain ( Surgical )
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Fractures
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Fractures
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Fractures
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Laceration
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Seizure
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Acute Psychiatric Ilnesses
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DM
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DKA
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Skin Rash
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• 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.?

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• 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

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Clinical ulterations in shock

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

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

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Clasification of shock

• 1-hypovolemic
• a-Hemorrhagic
• b-nonhemorrhagic
• 2-Cardiogenic
• Ischemic
• Myopathy
• Mechanical
• Arrhythmia

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

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

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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

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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

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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

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

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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

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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

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

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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

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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

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

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Management Of Obstructive Shock

• Directed Mainly to Management of the cause

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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

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• 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

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• Oxygen demand should also be reduced

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In Summery

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

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Reference book and the relevant page numbers..
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Thank You ?

• Dr.