FIRST HAND DESCRIPTION OF MANAGEMENT OF EMERGENCIES IN ER FOR MEDICAL OFFICERS

1. MANAGEMENT OF
MEDICOLEGAL EMERGENCIES
- AN INTENSIVIST ‘ S
PERSPECTIVE
Dr Vaidyanathan.R DA,DNB
Consultant anaesthesiologist and intensivist
CAUVERY HOSPITAL
MYSORE

2. MEDICOLEGAL CASES
• A medico-legal case is a case of injury/
illness where the attending doctor, after
history and examination thinks that some
investigation by law enforcement agencies
is essential to establish and fix
responsibility for the case in accordance
with the law of the land.
• Simply put, it is a medical case with legal
implications or a legal case requiring
medical expertise.

3. EMERGENCIES
• Any acute medical, surgical or obstetric
condition which deteriorates rapidly often
leading to death .
• Timely and immediate intervention by
trained personnel saves lives.
• Often involves Intensivist or emergency
medicine consultants early in management
• Multidisciplinary approach

4. THE EMERGENCIES
• Polytrauma
• Poisoning
• Drug overdosages
• Burns
• Assaults
• Gun shot injuries
• Drowning
• Hanging
• Snake /animal bite
TYPICAL ER or EMERGENCY ROOM

5. Cont’d…
• Cases of suspected or evident sexual assault.
• Cases of suspected or evident criminal abortion.
• Cases of unconsciousness where cause is not
natural/ not clear
• Cases of suspected self-infliction of injuries or
attempted suicide
• Death /arrest in the operation theatre
• Brought dead to the casualty/Accident and
Emergency dept / deaths occurring within 24
hours of hospitalization without establishment of
diagnosis

6. PROCEDURE
• In the casualty - first priority is to save the
life of the patient.
• He should do everything possible to
resuscitate the patient and ensure that he is
out of danger.
• All legal formalities stand suspended till
this is achieved.

7. PRECAUTIONS
• Consent
• Confidentiality
• Collection and preservation of
samples
• Preparation of medico-legal reports
in duplicate

8. Polytrauma
Airway – and total spine control
Breathing – and ventilatory support.
Circulation – with haemorrhage control.
Disability – brief neurological evaluation.
Exposure – completely undress the patient

9. AIRWAY
Mandatory intubation in
• GCS < 9
• Severe facial injury or bleeding.
• Severe facial or neck burns
Anticipate airway problems in all patients
with trauma to:
• Head & Neck
• Upper Thorax

10. AIRWAY - Cont’d
• Restlessness, decreased LOC = Hypoxia
until proven otherwise
• Oxygenate, Look for cause
• Oxygen is useless if patient isn’t ventilating
Danger Signs
• Respirations <10
• Respirations >24
• Decreased tidal volume
• Labored breathing

11. BREATHING AND VENTILATION
• Rapid assessment of respiratory rate, Spo2,
trachea , chest expansion and auscultation.
• Tension pneumothorax & haemothorax - immediate
needle thoracocentesis
Always exclude the following
1) Tension pneumothorax
2) Massive haemothorax
3) Open pneumothorax
4) Flail chest
5) Pericardial tamponade

12. CIRCULATION &
HAEMORRHAGE CONTROL
• Restlessness and anxiety especially with pallor,
tachycardia, or slow capillary refill =
• Falling BP = Late sign of shock
• Don’t treat a falling BP - Prevent It!!
SHOCK

13. Cont’d
• If shock present without external
bleeding, think:
– Thoracic or abdominal bleed
– Pelvic fracture
– Multiple long bone fractures
– Tension pneumothorax
– Cardiac tamponade

14. Cont’d
• Isolated head trauma does NOT cause
decreased BP in adults
• Look for injuries of:
– Chest
– Abdomen
– Pelvis
– Major long bones

15. CONT’‘ D
• Orthopedic injury usually NOT life-
threatening
• Exceptions:
–Pelvic fracture
–Femur fractures
• Assess, treat proximal to distal
• Insert 2 large IV cannula.

16. CONT ‘ D
• If you don’t know the diagnosis. . .
Open, clear, maintain airway
Maximize oxygenation, ventilation
Maximize perfusion

17. TRAUMA CARE
CONCLUSIONS• Definitive Treatment = Surgeon’s Knife
• Trying to field-stabilize unstable trauma = Ultimate
Stabilization
• Minimum time on scene ; Maximum treatment in route
• Patient MUST go to facility able to continue care
appropriately
• Closest facility, facility preferred by family is NOT
necessarily most appropriate
DEATH

18. TRAUMA CENTRE

19. When Trauma Deaths Occur
19
<1 hour 1-3 hours 4 to 6 weeks
“The Trimodal Distribution

20. Immediate Deaths(<1 hour)
• Loss of Airway
• Brain Stem Laceration
• High C-Spine Lesion
• Aortic/Heart Rupture
• What can be done about these
deaths?
20

21. 21
Early Deaths (1-3 hours )
• Epidural Heamatoma
• Subdural Heamatoma
• Hemo/Pneumothorax
• Intra-abdominal Bleeding
• Pelvic Fractures
• Femur Fractures
• Multiple Long Bone Fractures
Why do these
patients die?
Why do these
patients die?

22. 22
Late (2-4 weeks)
• Sepsis
• Multiple Organ System Failure
How can these deaths be
avoided?
How can these deaths be
avoided?

23. 23
Trauma Care Conclusions
• Definitive Trauma Care = Surgeon’s Knife
• Short time to surgery = Improved survival
• EMS improves survival by:
– Recognizing critical trauma
– Supporting oxygenation, ventilation, perfusion
– Transporting rapidly to definitive care
“The golden hour” concept
-the platinum few minutes

24. 24
RECOGNIZING THE GOLDEN HOUR
AND PLATINUM MINUTES !
• Where should the patient go?
The most
appropriate
facility Not
necessarily the
closest one!

25. FEW CASES
25

26. CONT’D
26

27. BACK TO NORMAL WAYS!
27

28. THE EDHs
28

29. THE EDHs cont’d
29

30. POISONING AND DRUG
OVERDOSES
• 12% of all ICU admissions in India
• 30% of patients requiring ventilatory
support
• 75% of all admissions due to poisonings
• MORE THAN 50% OF ICU ADMISSIONS IN CAUVERY
HOSPITAL REQUIRING VENTILATION

31. MANAGEMENT
General Measures
• Decontamination of the skin is very important and
done thoroughly.
• Forced emesis if the patient is fully awake or
through a gastric lavage.
• 0.5-1 g/kg activated charcoal every 4 h. Sodium
sulfate or sorbitol can be used as a cathartic.
• Serotonin adipinate

32. Cont’d
• The airway - adequate oxygenation should be
ensured.
• Atropine can precipitate ventricular arrhythmia in
hypoxic patients.
• Early use of atropine - reduces respiratory secretions,
improve muscle weakness, and thereby improve
oxygenation.
• Careful observation - as these patients are prone to
respiratory failure during the acute phase and
intermediate syndrome.

33. Things to look for…..
The important parameters to be monitored on a
regular basis are
• Symptoms of ocular muscle involvement (e.g.;
diplopia),
• Neck muscle weakness
• Tidal volume / vital capacity/RR
• Single breath count
• Arterial blood gas estimation or pulse oximetry.

34. Specific therapy
Anticholinergic Agent
• Mainstay of treatment
• Atropine can be started initially as a 2.4mg IV
bolus and then repeated at doses of 2-5 mg IV
bolus every 5-15 min until atropinization is
achieved.
• Most commonly used regimen is 0.2mg/kg/hour
titrated to desired effect

35. Target end-points for Atropine
therapy
• Heart rate >80/ min, Systolic blood pressure >80
• Dilated pupils
• Dry axillae ,Drying of all secretions
• Chest clear of secretions and crepts.

36. Oximes
• PRALIDOXIME (2-PAM).
– OPCs bind and phosphorylate one of the active sites of
AChE and inhibit the functionality of this enzyme.
– Oximes bind to the OP causing the compound to break
its bond with AChE – REACTIVATION.
– AGEING IS A CONCERN.
• The main therapeutic effect of pralidoxime is due to recovery
of N-M transmission at nicotinic synapses.
• However, oximes also enhance cholinesterase activity at
muscarinic sites decreasing the requirement for atropine.

37. Supportive measures
• Never forget co-existing diseases and
medical conditions
• Primarily supportive
• VAP-protocol
• DVT prophylaxis and thromboembolism
prevention
• “ FAST HUG ME ”

38. Sample spectrum of op poisoning
38

39. BURNS
• Classification-Degree and percentage of
burns
Major burns
• 3rd
degree or full thickness involving more than 10% BSA
• 2nd
degree or partial thickness involving more than 25%
BSA
• Burns involving face, hands and feet
• Inhalational /chemical /electric burns and burns in pts with
co-existing medical diseases.

40. ABC IN BURNS
• Secure airway early, as intubation is likely to be
difficult once edema has set in.
• In a child nasal intubation is preferred over oral
• Smoke inhalation and ALI
• CO poisoning.
• Eschorotomies

41. circulation
• Parkland formula
4ml/kg/% of BSA burnt
50% of it in first 8hrs
25% each in remaining 8 hrs each
• Mount vernon regimen
• Brook’s formula
• Modified brook’s regimen

42. DROWNING
• ABCs – maintain airway at earliest
• Always keep in mind drug and alcohol
intoxication
• Beware of prognosticating only with pupil size
and reaction
• Hypothermia ----cerebroprotective!!!
• Consider mannitol and diuretics

43. Attempted Hanging
• ABCs
• Secure airway, cervical spine control
• Liberal use of steroids
• Cerebral edema and hypoxia– major
determinant
• Mannitol
• Supportive measures.

44. Description of Ligature mark

45. INTENSIVIST - ICU !!!
Oh. GOD!!! NO WAY

47. Wish you Happy new year