1. 1

2. EMERGENCY MEDICINE:
Principles & Practice
Prof. Syed Amin Tabish
FRCP (London), FRCP (Edin.), FAMS, MD
2

3. Goals of a Health System
 Health
is fundamental to quality of life
 All human beings have an equal right to
heath
The Ideal Health system has to achieve:
 Attaining Good health for all people
 Being responsive to the expectations of the
people
 Maintaining fairness in allocation of
resources for obtaining service
3

4. Health For All
The
universal goal of the Health
System is to ensure adequate
access to quality care at a
reasonable cost
Achieving Health for All requires:
Primary Health Care (Key to HFA)
Emergency Care
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5. Morbidity & mortality
 Rapid
industrialization & urbanization
 Motor Vehicle accidents are the leading
cause of death by injury and the 10 th.
leading cause of all deaths
 Violence: political unrest, conflictrelated, militancy-related episodes, war
 Disasters: natural, man-made including
technological disasters
 Emergent infection: SARS, Bird flu,
Plague, Influenza, etc.
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6. Injury Prevention/Disease
Identification
Several health care issues have become
important to the public and the medical
profession:
 Real public health threats such as
injury, injury prevention, substance
abuse, violence, etc.
 These issues represent a major cost to
society, both in terms of medical
expenditures as well as lost productivity.
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7. EMERGENCY MEDICINE
Emergency Medicine is in a unique
position in the health system:
 The
interface between community care and
hospital care and is usually well integrated
with the community services (general
practitioner, ambulance service, district
nursing), with outpatient services conducted
by hospitals and with inpatient services
 EM: ideally situated to demonstrate the
relationship between these.
 The public expects that all medical students
and physicians are capable of providing care
for medical emergencies - care for all ages
and all diseases, either illness or injury.
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8. EM: Scope
 Patients
present to Emergency Departments
with problems rather than diseases,
highlighting the importance of a problembased approach to clinical decision making
 Emergency Medicine is integrated both
horizontally (with other clinical disciplines) and
vertically (with basic science and applied
science disciplines). Emergency Medicine is
Multidisciplinary.
 These features make Emergency
Departments ideal learning environments for
medical students.
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9. EM: Scope (contd.)
 All
doctors should possess general skills
and knowledge regarding emergency care of
the acutely ill or injured patient.
 There is a need for every medical school
graduate to handle emergencies as they
arise in the daily practice of medicine.
 The assessment and management of
emergencies is a central component of
medical education encompassing principles
that apply to all clinical disciplines.
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10. EM: Scope (contd.)
 The
emergency department (ED) provides a
unique educational experience that is distinct
from both inpatient and ambulatory care
settings.
 Because of the high acuity, interesting
pathology, and rapid patient turnover, the ED
is an ideal location to train medical students.
Numerous teaching opportunities exist within
the domain of the ED.
 OBJECTIVE: Saving lives and limbs,
reducing disability
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11. Scope (contd.)
Encounters such as the acutely poisoned or
intoxicated patient, environmental
emergencies, interaction with out-ofhospital providers, and patients requiring
emergency procedures are just a few
situations that make emergency medicine a
distinct clinical specialty.
Essential elements to create a progressive learning
environment over the entire undergraduate
educational experience include:
 Resuscitation room
 The undifferentiated problem
 Health system management
 Common minor problems
11

12. EM: Unique Content
Content areas unique to EM include:
Out-of-hospital care involves medical care in the
community.
 Toxicology offers the medical student a good
correlation between biochemistry, pharmacology,
and clinical medicine. Many poisoned patients also
require resuscitative and critical care skills.
 Environmental disease and injuries such as
bites and stings, dermatitis, burns, disorders of
temperature, near drowning or lightning injuries
commonly present in the ED.
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13. Components of EM
 Cardiopulmonary
 Basic
resuscitation
first aid
 ED/EMS observation
 Injury prevention/disease identification
 Approach to patient with life or limb threatening
disease - case correlation with pathology,
pharmacology, pathophysiology courses.
 Procedures - suturing, splinting, basic airway
management, intubation, IVs, NGT placement
 Focus on the acutely ill or injured patient
 The coordination of treatment with other physicians
and health services.
13

14. Triage
Medical
prioritization and triage
decision making
Triage is the process used to sort
patients in order of acuity or the
severity of illness
Right Patient at Right Place at the
Right Time
The utilization of scant resources
and the ability to prioritize care with
minimal or incomplete information
14

15. Resuscitation Presentations
 Major
topics to be addressed include:
"collapse", chest pain, shortness of breath,
altered conscious state and the multiply
injured patient.
 Procedures appropriate to this section are
basic life support, advanced cardiac life
support and the assessment and
management of the multiply injured . The
emphasis is on rapid assessment skills
and airway, breathing and circulation
procedures.
15

16. The Undifferentiated Problem
 Many
patients present to ED with
undifferentiated problems for example
abdominal pain, headache and dyspnoea
 Students should learn about linking the
clinical task with clinical decision making
and practice.
 Also know how to use investigations to
assist (not direct) the decision making
process.
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17. The Undifferentiated Problem (contd.)
Procedures include:
• history taking
• clinical examination
• documenting of findings
• charting and measurement of vital signs including
pulse, blood pressure, temperature and Glasgow
Coma Score
• performance of bedside tests such as urinalysis,
ECG, venepuncture, intravenous access,
catheterization of the bladder and stomach and
administration of oxygen and nebuliser therapy.
17

18. Other Common Problems
A
number of non-life threatening problems include
the assessment and management of soft tissue
injuries and infections, extremity injuries, burns
and otolarygological (ENT) and ophthalmological
problems.
 Relevant procedures to be learnt include
examination of the neurovascular system,
tendons, ears, eyes, nose and throat, local
anesthetic techniques, soft tissue injury repair,
joint dislocations and the reduction and
management of minor fractures.
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19. General Skills
General Assessment Skills
Such skills include:
 focused patient history
 physical diagnosis
 medical decision making
 exposure to a broad base of
"undifferentiated" patients and a wide
variety of personal and social issues
that influence patient care. 19

20. Life-saving Resuscitation Skills
All physicians should
learn recognition of
life-threatening
situations and
initiation of
resuscitation skills.
20

21. Life - saving procedures
Airway management and intubation
 Augmentation of circulation



Hemorrhage control
Limb stabilization
 Suturing
 Splinting
 Central
line insertion
 Defibrillation
 Respiratory and circulatory support, IV's,
NGT's


Neurologic treatment
care for the acutely psychotic and the poisoned
patient
21

22. EM: Clerkship





Perform an appropriately directed history and
physical examination
Recognize emergent and urgent problems
Develop a differential diagnosis for common
presenting complaints such as chest pain,
shortness of breath, abdominal pain.
Develop an appropriate and cost-effective
management plan for the ED patient presenting
with common complaints such as acute asthma
exacerbation, congestive heart failure,
bronchitis, etc.
Demonstrate proper wound care and suture
technique for simple lacerations.
22

23. EM Clerkship (contd.)
 Recognize
ischemic patterns and
arrhythmias on EKG tracings.
 Appropriately interpret results of complete
blood count, chemistries, urinalysis, arterial
blood gases, and the common laboratory
studies.
 Appropriately interpret radiographs (X ray)
of the chest, abdomen, and extremities .
 Recognize the indications for specialty or
subspecialty consultation.
23

24. Toxicology/Hazmat
Know the
principles of:
 biochemistry
 pharmacology
 pathophysiology
as they relate to poisoning
and hazardous material
24

25. Trauma
One of the leading causes of
disability and premature
death
 Know the epidemiology,
pathophysiology and
principles of treatment.

25

26. Specific Patient Care
Specific clinical conditions:
The approach to the patient
with:
short of breath
altered mental status
chest pain
multiple injuries
hypertension
 pregnant patient
The pediatric patient
26

27. Other Skills
 To
gain first-hand experience with
airway management (bag-valve-mask
and oxygen administration, etc.),
hemorrhage control, fluid resuscitation,
limb stabilization and CPR in the ED
 Universal Precautions to be observed
 Emergency Preparedness
- Code Blue: for management of Cardiopulmonary Arrest
- Code Yellow : for poly trauma/ mass casualties
- Code Green/Black: Disaster Management
 Legal
Aspects of Emergency Care
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28. Management of the Health Care System
 Emergency
physicians often act as
"gatekeepers" and are responsible for
the coordination of a patient's care
among outpatient clinics, observation
services and patient transfer.
 The ED provides an ideal environment
to educate the medical student on
appropriate consultation practices and
referral to other health care services,
while providing cost-efficient care.
28

29. MINIMUM LIBRARY RECOMMENDATIONS
 Cambridge
Textbook of Accident and
Emergency Medicine edited by David V Skinner, J
W Rodney Peyton, Colin E Robertson, Andrew Swain
 Emergency Medicine:
Guide
A Comprehensive Study
by American College of Emergency Physicians
 Principles
and Practice of Emergency
Medicine by Schwartz, George R.
Baltimore: Williams & Wilkins, 1999.

Emergency Medicine Manual
by O. John Ma, David M. Cline, Judith E. Tintinalli
 Emergency
practice
Medicine: Concepts and clinical
Eds: Rosen P, Baker FJ, Barkin RM
29

30. JOURNALS

Emergency Medicine. Australasian Society for Emergency
Medicine.

Annals of Emergency Medicine. American College of
Emergency Physicians

Journal of Emergency Medicine. Permagon Press

Emergency Clinics of North America. WB Saunders
Company

Emergency Medical Abstracts. Ed: Hasapes GA

Medline
30

31. THANK
YOU
31

32. THANK
YOU
32

33. Head trauma
Injurie s a re the le a ding ca us e of de a th in childre n, a nd
bra in injury is the mos t common ca us e of pe dia tric
tra uma tic de a th.
The a utomobile is the mos t le tha l compone nt of a
child's e nvironme nt.
33

34. Head trauma: statistics
• 200-300/100,000 pe r a nnum
• $7.5 Billions pe r a nnum in the US A
• multiple a e tiologie s
–
–
–
–
a utomobile s
a bus e
fa lls (bike s , s ka te boa rds , ATVs , wa lke rs ,windows )
mis s ile s (la wn da rts , bulle ts )
34

35. Pediatric head trauma
•
ma tura tiona l diffe re nce s
ha ve implica tions for
a s s e s s me nt a nd
prognos tica tion
– the young child's bra in
pre s e nts a diffe re nt
de ve lopme nta l s ubs tra te for
injury
35

36. Coma can result from:
• diffus e a xona l injury
• bra ins te m injury
• bila te ra l he mis phe ric da ma ge
36

37. Subdural vs . epidural
LifeArt: Williams & Wilkins
http://www.lifeart.com
37

38. Subdural hematoma I
•
is ve nous in origin (bridging
ve ins )
•
is a s s ocia te d with a
re a s ona ble outcome if
re move d e a rly
WebPath: University of Utah
http://www-medlib.med.utah.edu/WebPath/webpath.html
38

39. Subdural hematoma II
•
is ve nous in origin
(bridging ve ins )
•
is a s s ocia te d with a
re a s ona ble outcome if
re move d e a rly
WebPath: University of Utah
http://www-medlib.med.utah.edu/WebPath/webpath.html
39

40. Subdural hematoma III
•
us ua lly a ris e from the
bridging ve ins
•
bridging ve ins a re more
s us ce ptible to te a ring
whe n the re is cortica l
a trophy
WebPath: University of Utah
http://www-medlib.med.utah.edu/WebPath/webpath.html
40

41. Subdural hematoma resection
•
•
dura is bluis h, dis colore d,
te ns e
•
QuickTime™ and a
Sorenson Video decompressor
are needed to see this picture.
vide o of s ubdura l
he ma toma re s e ction
pre s s ure on corte x
re lie ve d upon re s e ction of
dura
DogByte Productions
Oregon Health Sciences University
41

42. Epidural hematoma I
•
is a rte ria l in origin
•
middle me ninge a l a rte ry is
torn
•
ofte n is a true ne uros urgica l
e me rge ncy
WebPath: University of Utah
http://www-medlib.med.utah.edu/WebPath/webpath.html
42

43. Epidural hematoma II
WebPath: University of Utah
http://www-medlib.med.utah.edu/WebPath/webpath.html
43

44. Hematoma: distortion
•
he ma toma dis pla ce s bra in
towa rd the right
•
s tra in or dis tortion of bra in
tis s ue vis ua lize d
colorime trica lly: de e p blue low
dis tortion, a nd ye llow a nd re d
high dis tortion or s tre tching
•
in this ca s e the re is a bout
17% dis tortion
http://www.neurosurgery-neff.com/trauma_research.html
44

45. Hematoma: interstital pressure
•
inte rs titia l pre s s ure is
de picte d
•
a lthough the midbra in
is in conta ct with the
te ntoria l incis ura , the
mos t gre a tly a ffe cte d
pe rfus ion is within the
ips ila te ra l he mis phe re
http://www.neurosurgery-neff.com/trauma_research.html
45

46. Intracerebral hemorrhage
•
is us ua lly fronta l or
te mpora l lobe
•
ca n be bila te ra l
(contracoup injury)
46

47. Focal injury
•
is us ua lly fronta l
or te mpora l lobe
WebPath: University of Utah
http://www-medlib.med.utah.edu/WebPath/webpath.html
47

48. Co up - c o ntra c o up injury
•
a fa ll ba ckwa rds
re s ulte d in
bila te ra l injury
•
infe rior fronta l
a nd te mpora l
lobe s
WebPath: University of Utah
http://www-medlib.med.utah.edu/WebPath/webpath.html
48

49. Co up - c o ntra c o up injury
LifeArt: Williams & Wilkins
http://www.lifeart.com
49

50. Cerebral perfusion scan
50

51. Cerebral perfusion scan II
51

52. Thank
you
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