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Disease Identification and Injury Prevention Accident & Emergency Module Lecture II Norah Al-Khathlan MD Objectives At the end of this lecture you should be able to: 1. Identify age specific disease presentation to emergency room. 2. Define injury. 3. Recognize the importance of injury prevention 4. Outline the presentation and management of patients with poisoning. Content • Describe a common approach in prioritizing patients. • List a common life threatening illnesses that may affect patient coming to emergency room with different ages • Define injury and list some typical injury patterns. • List the preventive measures at levels of home, work and environment. • List some of the toxidromes. • Outline the general management of the patient with poisoning. • Introduction to bites and stings. Assessment of the Emergency patient • • The need for sorting or prioritizing patient coming to emergency room ( triage concept). The approach to identifies life threatened patient ( 3 components ) 1. 2. 3. A chief complaint and a brief focused history relevant to the chief complaint A complete and accurate set of vital signs with critical interpretation An opportunity to visualized , auscultate and touch the patient Assessment of the Emergency patient • If you have a life threat condition, act immediately to reverse the condition – e.g. upper airway obstruction – positioning, suctioning , intubation • After stabilizing the pt, formulate the differential diagnosis – The most series comes first not the most common ( e.g. chest pain ---myocardial infarction 1st not costochondritis, fever in neonates ---neonatal sepsis not URTI) Assessment of the Emergency patient • Conduct and follow through a workup for the differential diagnosis. • Reassess patient for response to the treatment. • Identify patients who need further emergency treatment vs. consultations vs. admission with or without final diagnosis. Identify those who maybe safely discharged home. Life Threatening Presentations • Respiratory distress – Upper airway obstruction • Foreign body vs. Croup vs. Epiglottitis vs. Trauma vs. mass effect – Lower airway obstruction • BA , broncholytis • Vomiting & diarrhea – Dehydration : Moderate vs. Severe vs. Shocked • Fever: – Meningitis vs. Pneumonia vs. URTI – In neonate --- neonatal sepsis Red Flags in Emergency Room • • • • • • • • • Airway obstruction Respiratory distress Fever in neonate Abnormal vital sign e.g. hypotension , tachycardia Decrease level of conciseness Seizures Chest pain Multiple trauma Toxic overdose CTAS 5 Canadian Triage & Acuity Score I. Resuscitation: • Life/Function threatening eg: code, arrest, shock, coma • Time to Physician: Immediate II. Emergent: • • • III. Potential threats to life or function Time to Physician: < 15 minutes Severe trauma, altered LOC, Stroke, overdose, chest pain. Urgent: • • • IV. Potential progression into serious problems. Time to Physician: < 30 mins Moderate asthma, moderate trauma, vaginal bleeding Semi Urgent : • • V. Potential for deterioration Time to Physician: < 60 mins Non urgent: • • Acute but not urgent or part of chronic problem, can be seen at other areas. Minor Lacerations, sore throat, chronic mild abdominal pain • Time to physician: 120 mins II- Injury Definition: • Injury: Physical damage due to transfer of energy ( kinetic, thermal, chemical, electrical, or radiant) • Absence of oxygen or heat • Over a period of time, “exposure” that is either acute or chronic Typical Injury Patterns • • • • • • 80% blunt, 20% penetrating MVAs, gun shot wounds, falls Drowning, poisonings Carries a 9% global mortality. 5th leading cause of death in USA (1996) First, age 1 through 44 (1996) Typical Injury Patterns • Disability far exceeds death rate • First, age 1 through 44 • “Years of life lost” (YLL) concept: Life expectancy for young shortened by death from injury Numbers comparable with YLL from heart disease and cancer Most productive members of society! Injury not Accident !! • Accident: An unexpected occurrence, happening by chance • Injury: A definable, correctable event, with specific risks for occurrence • A result of risk poorly managed • “Disease of injury” concept • Injury can be prevented! III- Prevention of Injury “Prevention is the vaccine for the disease of injury.” • Host • AGENT • Environment A causal relationship! Prevention of Injury The 4 E’s: • • • • Education Enactment/Enforcement Engineering Economic incentives and penalties Prevention of Injury Categories of injury prevention: • Primary prevention: Eliminate the event • Secondary prevention: Diminish effect • Tertiary prevention: Improve outcomes Prevention of Injury Examples of effective injury prevention: • Highway speed limits. • • • • • Seat belt laws. Child passenger restraint laws. Apartment window guards. Smoke detectors. Violence/penetrating injury programs. VI- Poisoning • Definition of Poisoning: – Exposure to a chemical or other agent that adversely affects functioning of an organism. • Circumstances of Exposure can be intentional, accidental, environmental, medicinal or recreational. • Routes of exposure can be ingestion, injection, inhalation or cutaneous exposure. “All substances are poisons...the right dose separates poison from a remedy.” Toxidromes Constellation of signs & symptoms seen in poisoning characterized by the type of substance. Major four toxidromes are: – Anticholinergic – Sympathomimetic – Opiates/Sedatives- Hypnotics/ Alcohol – Cholinergic Poisoning Examples: • ASA • Acetaminophen • TCA • Narcotics & drugs of abuse • Benzodiazepines • Iron supplements • Alcohol Poisoning ABC’s of Toxicology: • Airway • Breathing • Circulation • Drugs: • • • Draw blood: • • • • • Resuscitation medications if needed Universal antidotes chemistry, coagulation, blood gases, drug levels Decontaminate Expose / Examine Full vitals / Foley / Monitoring Give specific antidotes / treatment Poisoning Universal Antidotes: 1. 2. 3. 4. Oxygen Glucose Naloxone “Narcan” Thiamine Poisoning • Decontamination: 1. Ocular: – 2. Dermal: – – – 3. Flush eyes with saline Remove contaminated clothing Brush off Irrigate skin Gastro-intestinal: – Activated charcoal: – – – – May Prevent /delay absorption of some drugs/toxins Almost always indicated Naso/oro-gastric Lavage Bowel Irrigation: – – – – – Recent ingestions 4-6 hrs Awake alert patient 500 cc NS Children / 2000cc adults Orally / Nasogastric tube Contraindications…? Bites & Stings Types: • Mammals • Human • Canines • • • • Snakes Scorpions Bees Others Bites & Stings Clinical Presentation: • Pain • Wounds • Swelling • Bleeding • Neurological • Infection • Shock Bites & Stings Management outline: • A. B. C. & D. approach. • Identify the culprit. • Obtain goal-directed history & Physical. • Reassure & calm the victim. • Wound care. • Obtain labs • Administer: – Fluids – Antivenin and/or vaccine, Immunoglobulin – Supportive therapy: analgesics. Antibiotics and blood products, • Follow up References • BLS manual for health providers AHA 2006 • Emergency Medicine, a comprehensive study guide; Tintinalli et al • Emergency Medicine MCCQE 2000 Review Notes & lecture series; Dr D. Cass et al “Free download from Internet”