Emergency medicine

EMERGENCY MEDICINE : that specialty which deals with acutely ill or injured patients who require immediate medical treatment
(see also natural catastrophes

and non-governmental organizations (NGO)

)

emergence : the process of coming out of a former state, as the restoration to a normal physiological state of an anesthetized patient.

emergency : an unlooked for or sudden occasion; an accident; an urgent or pressing need

aid : help or assistance; by extension, applied to any device by which a function can be improved or augmented, as a hearing aid.

first aid : the initial emergency care and treatment of an injured or ill person before definitive medical and surgical management can be secured

basic life support (BLS) algorythm : the ABC rule

airways
breathing
cardiopulmonary resuscitation (CPR) : the restoration to life or consciousness of one apparently dead; the artificial substitution of heart and lung action as indicated for cardiac arrest or apparent sudden death resulting from electric shock, drowning, respiratory arrest, and other causes. The 2 major components of CPR are :

nonmechanical ventilation
cardiac or heart massage vs. only rhythmic abdominal compression (OAC-CPR)

timing for expired air resuscitation (EAR) :

adults : 15-18 breaths per minute
child : 20 breaths per minute

external chest massage

adults : lower half of sternum with 2 hands
children : lower third of sternum, 1 cm above xiphisternum with 1 hand
lower third of sternum with 2 fingers

timing for CPR (1 or 2 operator is the same) :

adult : 2 inflations : 15 compressions (5-8 cycles per minute)
child < 9 yo : 1 inflation : 5 compressions (20 cycles per minute)
infant < 1 yo : 1 inflation : 5 compressions (20 cycles per minute)

Protocol

cardiac arrest (VF /VT ) : transthoracic defibrillation :

adults :

higher-energy (200 J/200 J/360 J) escalating monophasic shocks
150 J biphasic shocks achieve higher rates of defibrillation and return of spontaneous circulation^ref1,
ref2

pediatric :

2-4 J/kg for monophasic shocks
1–2 J/kg for biphasic shocks. Higher biphasic doses (up to 4 J/kg) are not likely to be harmful and are more efficacious than equivalent monophasic shocks^ref. Biphasic shocks may be delivered in a fixed dose of 50 J by an AED. The use of AEDs in children < 1 year of age is not recommended, as in this situation these devices are unable to differentiate between shock-able and non-shockable rhythms (eg, VF vs. PEA))

=> CPR => i.v. access and intubate => set up 1 l NS drip to flush drugs => adrenaline

1 mg (children 0.01 mg/kg) i.v. bolus every 3-5 minutes => defibrillate 360 J within 60 seconds of adrenaline => repeat cycle of adrenaline and defibrillation 3 times => amiodarone 3-5 mg/kg i.v. over 30 minutes (add to 250 ml of 5% glucose (incompatible with NS)) => repeat cycles of defibrillation and adrenaline => consider alternative antiarrhythmic agents (e.g. class Ic antiarrhytmics

: sotalol 1 mg/kg over 15-30 minutes; lignocaine 1 mg/kg stat dose, then infusion at 4 mg per minute. May be used prophylactically after successful cardioversion of VF) => 360 J discharge every 30 seconds^{ref1,
ref2,
ref3,
ref4,
ref5,
ref6,
ref7,
ref8,
ref9,
ref10,
ref11,
ref12,
ref13,
ref14,
ref15,
ref16,
ref17,
ref18,
ref19,
ref20,
ref21,
ref22,
ref23,
ref24,
ref25,
ref26,
ref27}

cardiac asystolia : confirm asystole with at least 2 leads- check electrodes, monitor leads and monitor to ensure correct diagnosis => be suspicious if there is no electrical artifact with chest compression => if there is any doubt about whether the rhythm is asystole or fine VF treat as VF : CPR => IV Access +/- Intubate - set up 1L normal saline drip to flush drugs => CPR => i.v. access +/- intubate, set up 1 L NS drip to flush drugs => adrenaline 1 mg (children 0.01 mg/kg) i.v. every 3 minutes - repeat until arrest is over => atropine 1 mg (children 0.02 mg/kg) in every 3-5 minutes to total of 3 mg

in shocks in emergency setting the first medical intervention should be positioning of a vascular access device before veins collapse : for long-time positioning in antecubital fold place a flexible needle-cannula (despite once bent it loses elasticity) or use the forearm, wrist, or arm portions of cephalic vein The access can be used for blood sampling first and phleboclysis then (the first examination in hemorrhage should be blood group typization; the first examinations ehen acute myocardial infarction is suspected should be myocardial necrosis enzymes and coagulation profile). The first operation should be thawing of cryoprecipitates and platelet concentrates as hypothermia worsens acidosis
cannulation
intubation
catheterization
Rose's position : one intended to prevent aspiration or swallowing of blood, as from an injured lip: the patient is supine with head hanging over the end of the table in full extension so as to enable bleeding to be over the margins of the inverted upper incisors
Heimlich maneuver : a method of dislodging food or other material from the throat of a choking victim: after wrapping the arms around the victim at the belt line and allowing his upper torso to hang forward, make a fist with one hand and grasp it with the other; with both hands placed against the victim's abdomen slightly above the navel and below the rib cage, forcefully press into the abdomen with a quick upward thrust. If the victim is sitting, stand behind him and perform the same procedure; if he is prone, turn him on his back, kneel astride the torso, place both hands at the location on the victim's abdomen as described above and press forcefully with a sharp upward thrust. The maneuver may be repeated several times if necessary

Contraindications

pregnancy

The rate of survival after out-of-hospital cardiac arrest

is low. Training and equipping volunteers to attempt early defibrillation with automated external defibrillators (AEDs)

within a structured response system before paramedics arrive can increase the number of survivors to hospital discharge after out-of-hospital cardiac arrest in public locations from 14% to 23%. Trained laypersons can use AEDs safely and effectively^ref. Because paramedics often arrive relatively late, the research found the people they save are more likely to suffer brain damage: 78% of those saved by bystanders without paramedics survived with excellent brain function vs. 68% of those treated by paramedics^ref. The addition of advanced-life-support interventions did not improve the rate of survival after out-of-hospital cardiac arrest in a previously optimized emergency-medical-services system of rapid defibrillation. In order to save lives, health care planners should make cardiopulmonary resuscitation by citizens and rapid-defibrillation responses a priority for the resources of emergency-medical-services (EMS) systems^ref.

basic life support with defibrillator (BLSD)

pediatric basic life support (PBLS)

intermediate cardiac life support (ICLS)
advanced life support (ALS)

advanced cardiac life support (ACLS)
advanced trauma life support (ATLS) : endotracheal intubation if GCS <= 8

prehospital trauma care (PTC)

prehospital trauma life support (PHTLS)

emergency medical services (EMS)

emergency medical dispatch (EMD)

emergency medical physicians
emergency medical technicians (EMTs)

neonatal emergency transport service (NETS)
ambulance : a vehicle for conveying the sick or injured, and equipped with apparatus for rendering emergency treatment.

central district ambulance (CDA)

triage : 1. the sorting out and classification of casualties of war or other disaster, to determine priority of need and proper place of treatment. 2. by extension, the sorting and prioritizing of patients for treatment in nonemergency health care settings.