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Advanced life support emergencies

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Amr Eldakroury
Amr Eldakroury

Advanced life support (ALS). a higher level of emergency medical care, usually provided by EMT-intermediates or paramedics.

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EMERGENCIES IN GENERAL PRACTICE By Dr . NADER ALDABOUR
Cardiac emergencies • The signs and symptoms of cardiac emergencies include chest pain ! , shortness of breath, fast and slow heart rates, increased respiratory rate, low blood pressure ! , poor peripheral perfusion (indicated by prolonged capillary refill time) and altered mental state. • If there is a history of angina the patient will probably carry glyceryl trinitrate spray or tablets (or isosorbide dinitrate tablets) and they should be allowed to use them. • Where symptoms are mild and resolve rapidly with the patient’s own medication, hospital admission is not normally necessary. • Sudden alterations in the patient’s heart rate (very fast or very slow) may lead to a sudden reduction in cardiac output with loss of consciousness. • Medical assistance should be summoned by dialling 999.
Case. Myocardial infarction Symptoms and signs of myocardial infarction • Progressive onset of severe, crushing pain in the centre and across the front of chest. The pain may radiate to the shoulders and down the arms (more commonly the left), into the neck and jaw or through to the back. • Skin becomes pale and clammy. • Nausea and vomiting are common. • Pulse may be weak and blood pressure may fall. • Shortness of breath.
Advanced life support emergencies
localisation ST elevation Reciprocal ST depression coronary artery Anterior MI V1-V6 None LAD Septal MI V1-V4, disappearance of septum Q in leads V5,V6 none LAD-septal branches Lateral MI I, aVL, V5, V6 II,III, aVF LCX or MO Inferior MI II, III, aVF I, aVL RCA (80%) or RCX (20%) Posterior MI V7, V8, V9 high R in V1-V3 with ST depression V1-V3 > 2mm (mirror view) RCX Right Ventricle MI V1, V4R I, aVL RCA Help with the localisation of a myocardial infarct
Case. Myocardial infarction • Call 999 immediately for an ambulance. • Allow the patient to rest in the position that feels most comfortable; in the presence of breathlessness this is likely to be the sitting position. Patients who faint or feel faint should be laid flat; often an intermediate position (dictated by the patient) will be most appropriate. • Give high flow oxygen (10 litres per minute). • Give sublingual GTN spray if this has not already been given. • Reassure the patient as far as possible to relieve further anxiety. • Give aspirin in a single dose of 300 mg orally, crushed or chewed. Ambulance staff should be made aware that aspirin has already been given as should the hospital. • Many ambulance services in the UK will administer thrombolytic therapy before hospital admission. • If the patient becomes unresponsive always check for ‘signs of life’ (breathing and circulation) and start CPR in the absence of signs of life or normal breathing (ignore occasional ‘gasps’).
WITHOUT AED
WITH AED
TRAUMA. .
CASE - TRAUMA Trauma Assessment The initial assessment and management of seriously injured patients is a challenging task and requires a rapid and systematic approach. This systematic approach can be practised to increase speed and accuracy of the process but good clinical judgement is also required. Although described in sequence some of the steps will be taken simultaneously. The aim of good trauma care is to prevent early trauma mortality. Early trauma deaths occur because of failure of oxygenation of vital organs or central nervous system injury or both.
CASE – TRAUMA MANAGEMENT First and most important: Is it safe to approach?
CASE – TRAUMA MANAGEMENT •Aims of the initial evaluation of trauma patients • Stabilise the patient • Identify life threatening conditions in order of risk and initiate supportive treatment • Organise definitive treatments or organise transfer for definitive treatments •Preparation and coordination of care Assessment and management will begin out of hospital at the scene of injury and good communication with the receiving hospital is important. The preparatory measures are outlined below to 'set the scene':
CASE – TRAUMA MANAGEMENT • The prehospital phase • Preparation of a resuscitation area • Airway equipment (laryngoscopes etc accessible, tested) • Intravenous fluids (warming equipment etc) • Immediately available monitoring equipment • Methods of summoning extra medical help • Prompt laboratory and radiology backup • Transfer arrangements with trauma centre. • Guidelines on protection when dealing with body fluid should be followed throughout this and subsequent procedures.
CASE – TRAUMAMANAGEMENT General principles 1. Follow the Airway, Breathing, Circulation, Disability, and Exposure approach (ABCDE) to assess and treat the patient. 2. Treat life-threatening problems as they are identified before moving to the next part of the assessment. 3. Continually re-assess starting with Airway if there is further deterioration. 4. Assess the effects of any treatment given. 5. Recognise when you need extra help and call for help early. This may mean dialling 999 for an ambulance. 6. Use all of your resources – ask members of public for help. This will allow you to do several things at once, e.g., collect emergency drugs and equipment, dial 999.
CASE – TRAUMA MANAGEMENT Initial assessment This comprises: • Primary survey • Resuscitation • Secondary survey • Definitive treatment or transfer for definitive care
CASE – TRAUMA MANAGEMENT • A= Airway maintenance cervical spine protection • B= Breathing and ventilation • C= Circulation with haemorrhage control • D= Disability: Neurological status • E= Exposure/ environmental control
CASE – TRAUMA MANAGEMENT As part of the secondary survey •History: • A=Allergies • M=Medication currently used • P=Past illnesses/Pregnancy • L=Last meal • E=Events/Environment related to injury
CASE – TRAUMA MANAGEMENT A= Airway maintenance cervical spine protection • Are there signs of airway obstruction, foreign bodies, facial, mandibular or laryngeal fractures? • Establish a clear airway (chin lift or jaw thrust) but protect the cervical spine at all times. If the patient can talk the airway is likely to be safe but remain vigilant and recheck. GCS less than 8 requires definitive airway.
CASE – TRAUMA MANAGEMENT B= Breathing and ventilation Evaluate breathing: lungs, chest wall, diaphragm. Chest examination with adequate exposure: watch chest movement, auscultate, percuss to detect lesions acutely impairing ventilation: • Tension pneumothorax • Flail chest • Haemothorax • Pneumothorax.
CASE – TRAUMAMANAGEMENT C = Circulation with haemorrhage control • Blood loss is the main preventable cause of death after trauma. To assess blood loss rapidly observe: • Level of consciousness • Skin colour • Pulse. • Bleeding should be assessed and controlled: • Direct manual pressure should be used (not tourniquets except for traumatic amputation as these cause distal ischemia). • Transparent pneumatic splinting devices may control bleeding and allow visual monitoring. • Occult bleeding into the abdominal cavity and around long bone or pelvic fractures is problematic.
Advanced life support emergencies
CASE – TRAUMA MANAGEMENT D = Disability: Neurological status • After A,B and C above rapid neurological assessment is made to establish • Level of consciousness, using Glasgow Coma Scale • Pupils: size, symmetry and reaction • Any lateralising signs • Level of any spinal cord injury (limb movements, spontaneous respiratory effort) • Note: remember oxygenation, ventilation, perfusion, drugs, alcohol and hypoglycaemia may all also affect level of consciousness.
CASE – TRAUMA MANAGEMENT E= Exposure/ environmental control • Undress patient, but prevent hypothermia Clothes may need to be cut off, but after examination attention to prevention of heat loss with warming devices, warmed blankets etc is important, Intravenous fluids should be warmed before infusion.
Thank You For All • .

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Advanced life support emergencies

  • 2. Cardiac emergencies • The signs and symptoms of cardiac emergencies include chest pain ! , shortness of breath, fast and slow heart rates, increased respiratory rate, low blood pressure ! , poor peripheral perfusion (indicated by prolonged capillary refill time) and altered mental state. • If there is a history of angina the patient will probably carry glyceryl trinitrate spray or tablets (or isosorbide dinitrate tablets) and they should be allowed to use them. • Where symptoms are mild and resolve rapidly with the patient’s own medication, hospital admission is not normally necessary. • Sudden alterations in the patient’s heart rate (very fast or very slow) may lead to a sudden reduction in cardiac output with loss of consciousness. • Medical assistance should be summoned by dialling 999.
  • 3. Case. Myocardial infarction Symptoms and signs of myocardial infarction • Progressive onset of severe, crushing pain in the centre and across the front of chest. The pain may radiate to the shoulders and down the arms (more commonly the left), into the neck and jaw or through to the back. • Skin becomes pale and clammy. • Nausea and vomiting are common. • Pulse may be weak and blood pressure may fall. • Shortness of breath.
  • 5. localisation ST elevation Reciprocal ST depression coronary artery Anterior MI V1-V6 None LAD Septal MI V1-V4, disappearance of septum Q in leads V5,V6 none LAD-septal branches Lateral MI I, aVL, V5, V6 II,III, aVF LCX or MO Inferior MI II, III, aVF I, aVL RCA (80%) or RCX (20%) Posterior MI V7, V8, V9 high R in V1-V3 with ST depression V1-V3 > 2mm (mirror view) RCX Right Ventricle MI V1, V4R I, aVL RCA Help with the localisation of a myocardial infarct
  • 6. Case. Myocardial infarction • Call 999 immediately for an ambulance. • Allow the patient to rest in the position that feels most comfortable; in the presence of breathlessness this is likely to be the sitting position. Patients who faint or feel faint should be laid flat; often an intermediate position (dictated by the patient) will be most appropriate. • Give high flow oxygen (10 litres per minute). • Give sublingual GTN spray if this has not already been given. • Reassure the patient as far as possible to relieve further anxiety. • Give aspirin in a single dose of 300 mg orally, crushed or chewed. Ambulance staff should be made aware that aspirin has already been given as should the hospital. • Many ambulance services in the UK will administer thrombolytic therapy before hospital admission. • If the patient becomes unresponsive always check for ‘signs of life’ (breathing and circulation) and start CPR in the absence of signs of life or normal breathing (ignore occasional ‘gasps’).
  • 10. CASE - TRAUMA Trauma Assessment The initial assessment and management of seriously injured patients is a challenging task and requires a rapid and systematic approach. This systematic approach can be practised to increase speed and accuracy of the process but good clinical judgement is also required. Although described in sequence some of the steps will be taken simultaneously. The aim of good trauma care is to prevent early trauma mortality. Early trauma deaths occur because of failure of oxygenation of vital organs or central nervous system injury or both.
  • 11. CASE – TRAUMA MANAGEMENT First and most important: Is it safe to approach?
  • 12. CASE – TRAUMA MANAGEMENT •Aims of the initial evaluation of trauma patients • Stabilise the patient • Identify life threatening conditions in order of risk and initiate supportive treatment • Organise definitive treatments or organise transfer for definitive treatments •Preparation and coordination of care Assessment and management will begin out of hospital at the scene of injury and good communication with the receiving hospital is important. The preparatory measures are outlined below to 'set the scene':
  • 13. CASE – TRAUMA MANAGEMENT • The prehospital phase • Preparation of a resuscitation area • Airway equipment (laryngoscopes etc accessible, tested) • Intravenous fluids (warming equipment etc) • Immediately available monitoring equipment • Methods of summoning extra medical help • Prompt laboratory and radiology backup • Transfer arrangements with trauma centre. • Guidelines on protection when dealing with body fluid should be followed throughout this and subsequent procedures.
  • 14. CASE – TRAUMAMANAGEMENT General principles 1. Follow the Airway, Breathing, Circulation, Disability, and Exposure approach (ABCDE) to assess and treat the patient. 2. Treat life-threatening problems as they are identified before moving to the next part of the assessment. 3. Continually re-assess starting with Airway if there is further deterioration. 4. Assess the effects of any treatment given. 5. Recognise when you need extra help and call for help early. This may mean dialling 999 for an ambulance. 6. Use all of your resources – ask members of public for help. This will allow you to do several things at once, e.g., collect emergency drugs and equipment, dial 999.
  • 15. CASE – TRAUMA MANAGEMENT Initial assessment This comprises: • Primary survey • Resuscitation • Secondary survey • Definitive treatment or transfer for definitive care
  • 16. CASE – TRAUMA MANAGEMENT • A= Airway maintenance cervical spine protection • B= Breathing and ventilation • C= Circulation with haemorrhage control • D= Disability: Neurological status • E= Exposure/ environmental control
  • 17. CASE – TRAUMA MANAGEMENT As part of the secondary survey •History: • A=Allergies • M=Medication currently used • P=Past illnesses/Pregnancy • L=Last meal • E=Events/Environment related to injury
  • 18. CASE – TRAUMA MANAGEMENT A= Airway maintenance cervical spine protection • Are there signs of airway obstruction, foreign bodies, facial, mandibular or laryngeal fractures? • Establish a clear airway (chin lift or jaw thrust) but protect the cervical spine at all times. If the patient can talk the airway is likely to be safe but remain vigilant and recheck. GCS less than 8 requires definitive airway.
  • 19. CASE – TRAUMA MANAGEMENT B= Breathing and ventilation Evaluate breathing: lungs, chest wall, diaphragm. Chest examination with adequate exposure: watch chest movement, auscultate, percuss to detect lesions acutely impairing ventilation: • Tension pneumothorax • Flail chest • Haemothorax • Pneumothorax.
  • 20. CASE – TRAUMAMANAGEMENT C = Circulation with haemorrhage control • Blood loss is the main preventable cause of death after trauma. To assess blood loss rapidly observe: • Level of consciousness • Skin colour • Pulse. • Bleeding should be assessed and controlled: • Direct manual pressure should be used (not tourniquets except for traumatic amputation as these cause distal ischemia). • Transparent pneumatic splinting devices may control bleeding and allow visual monitoring. • Occult bleeding into the abdominal cavity and around long bone or pelvic fractures is problematic.
  • 22. CASE – TRAUMA MANAGEMENT D = Disability: Neurological status • After A,B and C above rapid neurological assessment is made to establish • Level of consciousness, using Glasgow Coma Scale • Pupils: size, symmetry and reaction • Any lateralising signs • Level of any spinal cord injury (limb movements, spontaneous respiratory effort) • Note: remember oxygenation, ventilation, perfusion, drugs, alcohol and hypoglycaemia may all also affect level of consciousness.
  • 23. CASE – TRAUMA MANAGEMENT E= Exposure/ environmental control • Undress patient, but prevent hypothermia Clothes may need to be cut off, but after examination attention to prevention of heat loss with warming devices, warmed blankets etc is important, Intravenous fluids should be warmed before infusion.