Emergency Care in Family Medicine

• Emergency care is the provision of initial resuscitation, stabilization, and treatment to acutely ill and injured patients, and subsequent delivery of those patients to the best available definitive care.
• Family Practice is the medical specialty that provides continuing and comprehensive health care for the individual and his family in a holistic approach. It is the specialty that integrates the biologic, clinical, and behavioral sciences. It encompasses all ages, sexes, each organ system, and every disease entity.

Medical Triage

This is the process of prioritizing treatment that will make a difference to acutely ill or severely injured patients. It is essential to the philosophy of emergency care.

Acuity:

Is a combination of the illness itself and the potential for intervention that will change its course. It is not the same as the severity of the illness. Patients are not usually treated in the order in which they arrive but in order of acuity.

Guidelines for trauma triage

In accordance with the principles of ATLS, injured patients are assessed and treated based on their presenting vital signs values (Physiological Abnormalities), mental status, and Mechanism of injury.

PHYSIOLOGICAL ABNORMALITIES DURING VITAL SIGNS (In your vital signs, if any of the following is present, consider it as potential Major Trauma)

• Respiratory Rate: ≤ 8 or ≥ 20
• Blood Pressure: ≤ 90 mmHg for SBP or ≤ 50 mmHg DBP
• Pulse: ≤ 50 or ≥ 100/minute
• Conscious State: GCS ≤ 13
• Oxygen Saturation: ≤ 90%

PATTERN OF INJURY (In your General Examination, consider as major trauma if any one of the following is present)

• All penetrating injuries: (Head, Neck, Chest, Abdomen, Pelvic, Axillary, and groin)
• Blunt injuries:
  • Patient with a significant injury to a single region, e.g., head, neck, chest, abdomen, axilla, and groin
  • Patient with injuries involving two or more of the above body regions.

Specific injuries:

• Limb amputation/ limb-threatening injuries
• Suspected spinal cord injuries
• Burns ≥ 20% or with suspected inhalational injury
• Serious crush injury
• Major compound fracture or open dislocation
• Fracture to two or more of the following: Femur, Tibia, Humerus
• Fractured pelvis

MECHANISM OF INJURY

• Motor vehicle collision (MVC) with intrusion into passenger compartment
• MVC with major vehicular deformity > 20M
• Ejection from vehicle
• MVC with entrapments or prolonged extraction of > 30 mins
• Fall from height of > 20 ft
• MVC with fatality in the same passenger compartment
• Auto-pedestrian or auto-bicycle collision at 5 MPH vehicular roll-over

Timimg/prompt first AID saves life

Time is a significant factor in the application of Golden One Hour medical assistance

The time to plan, act, and participate is now...

Not after the event has occurred.

• Between TEN minutes - PLATINUM
• Within One Hour = GOLD

Checklist for every Emergency: DR.ABC - Letters that save lives

• D - Danger:
• Check carefully before going to the assistance of casualty, that it is safe for you - and them - to be there
• R - Response
• A - Airway
• B - Breathing
• C - Circulation

THINGS TO CHECK WHEN YOU FIRST ENTER A&E

• Required when supply of O2 to brain is insufficient to maintain function.
• O2 delivery is dependent on C.O, HB conc %sat of HB with O2.
• CPR required after cardiac arrest, respiratory arrest, or both.

CEREBRAL HYPOXIA

• Brain is sensitive to hypoxia. It has limited anaerobic metabolism and cannot store O2.
• Hypoxemia is tolerated in normal individuals → CBF (Cerebral Blood Flow) increases to compensate for reduced O2 carriage.
• When a patient is unable to increase CBF, anaerobic metabolism sets in.

CARDIAC ARREST

• Sudden cessation of effective cardiac output with consequent circulatory arrest.
• Sudden cessation of the circulation in a patient not expected to die at that time. (Famewo, 1980)
• Failure of the heart to maintain an adequate cerebral circulation in the absence of a causative or irreversible disease. (Gardiner, 1987)

Aetiology of Out of Hospital Cardiopulmonary Arrest

• Presumed cardiac disease (IHD) – leading cause.
• Non-cardiac internal aetiologies:
  • Lung disease
  • Cerebrovascular disease
  • Cancer
  • GI haemorrhage
  • Pulmonary embolism
  • Diabetes mellitus
• Non-cardiac external aetiologies:
  • Trauma
  • Asphyxia
  • Drug overdose
  • Drowning
  • Suicide
  • Electrocution
  • Lightning

Features of Cardiac Arrest

• Sudden deep unconsciousness
• Apnoea or occasional gasp
• Absence of pulsation in a large artery
• Pallor/greyness. Ashen cyanosis
• Dilated and unresponsive pupils (unreliable - morphine constricts)

Basic Life Support (BLS)

BLS refers to maintaining airway patency and supporting breathing and the circulation, without the use of equipment other than a protective device.

Basic Life Support (BLS) comprises of:

• Initial assessment
• Airway maintenance
• Chest compression
• Rescue breathing

Automated external defibrillator now has a place in early CPR Chain of Survival.

Chain of Survival

The actions linking the victim of sudden cardiac arrest with survival is C of S.

1. Early recognition and call for help to prevent cardiac arrest
2. Early CPR to buy time
3. Early defibrillation to restart the heart
4. Post resuscitation care to restore quality of life

Chain of survival

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Chain of survival

Survival Following Cardiac Arrest:

• 70% of cardiac arrests occur out of hospital.
• Early CPR improves outcome.
• Most cases of survival occur when the victim is in VF (ventricular fibrillation), and the effect of CPR is to prevent this rhythm from degenerating into asystole, which carries a poorer prognosis.
• A survival rate of 30% should be possible in a witnessed, out-of-hospital cardiac arrest victim in VF.
• In-hospital cardiac arrest: CPR may play a much lesser role compared with defibrillation and Advanced Life Support (ALS).

Adult BLS Sequence

1. Ensure safety of rescuer and victim.
2. Check victim and see if he responds.
3. If there is a response, leave in that position if no further danger, get help. Reassess.
4. No response, shout for help.
5. Open airway: Head tilt/chin lift. If C-spine fracture suspected, use jaw thrust (jaw lift with in-line C-spine immobilization).

Shake and shout for help

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Shake and shout for help

Opening airway- head tilt, chin lift

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Opening airway- head tilt, chin lift

Keeping Airway Open

• Look (chest)
• Listen (victim’s mouth)
• Feel (air on your cheek) for breathing.

If breathing, turn to recovery position.

ASSESS BREATHING- look, listen, feel 

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ASSESS BREATHING- look, listen, feel 

Recovery position after  

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Recovery position after  

Chest Compressions:

• Depress sternum 4-5 cm
• Rate: 100 per minute
• Effective chest compression does not produce more than 30% cerebral blood flow, so combine chest compression with rescue breath in a ratio of 30:2.

Chest compressions

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Chest compressions

Advance Life Support (ALS)

ALS starts when qualified help arrives or in hospital settings. When cardiac arrest is suspected, open the airway, start CPR 30:2 until defibrillator is attached, diagnose the rhythm.

ALS & Shockable Rhythm:

• If shockable rhythm, give one shock - 150-200J monophasic or 360J biphasic (waveform). Biphasic now in use.
• Then resume CPR sequence 30:2 for 2 minutes. If there is still VF/VT, give a second shock.

Reversible Causes of Cardiac Arrest

• (VT, VF, AS, PEA)

5 "H": Hypoxia, Hypovolaemia, Hypo/Hyperkalaemia/Metabolic, Hypothermia.

5 "Ts": Trauma, Tension pneumothorax, Tamponade (cardiac), Toxins (drug overdose/therapy), Thrombosis (coronary, pulmonary).