EMERGENCY MEDICINE

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EMERGENCY MEDICINE:
Principles & Practice
Prof. Syed Amin Tabish
FRCP (London), FRCP (Edin.), FAMS, MD (AIIMS)
Postdoc Fellowship (England)
Doctorate in Educational Leadership (USA)

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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

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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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Morbidity & mortality
 Rapid industrialization & urbanization
 Motor Vehicle accidents are the leading
cause of death by injury and the 10th.
leading cause of all deaths
 Violence: political unrest, conflict-
related, militancy-related episodes, war
 Disasters: natural, man-made including
technological disasters
 Emergent infection: SARS, Bird flu,
Plague, Influenza, etc.

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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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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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EM: Scope
 Patients present to Emergency Departments
with problems rather than diseases,
highlighting the importance of a problem-
based 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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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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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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Scope (contd.)
Encounters such as the acutely poisoned or
intoxicated patient, environmental
emergencies, interaction with out-of-
hospital 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

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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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Components of EM
 Cardiopulmonary resuscitation
 Basic 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.

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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

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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.

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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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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.

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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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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.

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

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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

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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.

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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.

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

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

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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

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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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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.

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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: A Comprehensive Study
Guide
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 Medicine: Concepts and clinical
practice
Eds: Rosen P, Baker FJ, Barkin RM

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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

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Head trauma
Injuries are the leading cause of death in children, and
brain injury is the most common cause of pediatric
traumatic death.
The automobile is the most lethal component of a
child's environment.

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• 200-300/100,000 per annum
• $7.5 Billions per annum in the USA
• multiple aetiologies
– automobiles
– abuse
– falls (bikes, skateboards, ATVs, walkers,windows)
– missiles (lawn darts, bullets)
Head trauma: statistics

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• diffuse axonal injury
• brainstem injury
• bilateral hemispheric damage
Coma can result from:
Coma can result from:

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

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• is venous in origin (bridging
veins)
• is associated with a
reasonable outcome if
removed early
Subdural hematoma I
Subdural hematoma I
WebPath: University of Utah
http://www
http://www-
-medlib.med.utah.edu/WebPath/webpath.html
medlib.med.utah.edu/WebPath/webpath.html

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• is venous in origin
(bridging veins)
• is associated with a
reasonable outcome if
removed early
Subdural hematoma II
Subdural hematoma II
http://www
http://www-

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• usually arise from the
bridging veins
• bridging veins are more
susceptible to tearing
when there is cortical
atrophy
Subdural hematoma III
Subdural hematoma III
http://www
http://www-

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• video of subdural
hematoma resection
• dura is bluish, discolored,
tense
• pressure on cortex
relieved upon resection of
dura
Subdural hematoma resection
Subdural hematoma resection
DogByte Productions
DogByte Productions
Oregon Health Sciences University
Oregon Health Sciences University
QuickTime™ and a
Sorenson Video decompressor
are needed to see this picture.

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• is arterial in origin
• middle meningeal artery is
torn
• often is a true neurosurgical
emergency
Epidural hematoma I
Epidural hematoma I
http://www
http://www-

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Epidural hematoma II
Epidural hematoma II
http://www
http://www-

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http://www.neurosurgery-neff.com/trauma_research.html
Hematoma: distortion
• hematoma displaces brain
toward the right
• strain or distortion of brain
tissue visualized
colorimetrically: deep blue low
distortion, and yellow and red
high distortion or stretching
• in this case there is about
17% distortion

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http://www.neurosurgery-neff.com/trauma_research.html
Hematoma: interstital pressure
• interstitial pressure is
depicted
• although the midbrain
is in contact with the
tentorial incisura, the
most greatly affected
perfusion is within the
ipsilateral hemisphere

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• is usually frontal or
temporal lobe
• can be bilateral
(contracoup injury)
Intracerebral
Intracerebral hemorrhage
hemorrhage

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• is usually frontal
or temporal lobe
Focal injury
Focal injury
WebPath
: University of Utah
http://www
http://www-

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• a fall backwards
resulted in
bilateral injury
• inferior frontal
and temporal
lobes
Coup
Coup -
- contracoup
contracoup injury
injury
WebPath
: University of Utah
http://www
http://www-

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Cerebral perfusion scan
Cerebral perfusion scan

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Cerebral perfusion scan II
Cerebral perfusion scan II

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