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Introduction to Emergency Medicine Dr. Tarek Atia Book: The new manual of basic emergency procedures; Firs aid and updated CPR By: Professor Mohamed A. Seraj 2nd edition A-2 Subspecialty of Emergency Medicine Pediatric Emergency Medicine Toxicology Sports Medicine Undersea and Hyperbaric Medicine Challenges to Emergency Medicine Interaction with difficult, intoxicated, or violent patients or family members Work in a “fishbowl” without 20/20 hindsight Finding follow-up or care for uninsured Limited resources High stress Scope to emergency medicine What make case emergency: 1. If acute 2. Life threatening 3. Chance of permanent morbidity. Asking question: I) Multiple casualty Within Take capability of the hospital. patient with most serious situation. II) Mass casualty Beyond capability of the hospital. Disaster – Take patient with least serious case .i.e: the least intervention. Clean the hospital. The golden hour: Expression that time after the accident is of the highest value. Because there is high chance to reverse the situation. THE EARLIER THE BETTER. So, there are two types of care: I) Pre-hospital care: • Consist of two types of supports: 1)Basic life support: • Without intervention. 2)Advanced life support. Like: intubations, Intra Venous line. With intervention. Very useful in cardiac patient. Harmful in trauma patient. Because this take the golden hour waiting for the ambulance. II)Hospital care: Behavior and treatment different between Emergency Room and word. Because in ER there is no time (deal with the core of the problem). – Approach to ER pt: History: – Allergy – Medication – Past illness/pregnancy. – Last meal. – Event/ environment. SMPLE Hx Primary survey: • Airway • Breathing • Circulation ABCDE STEP BY STEP • Disability (CNS). • Exposure/ Environment: expose pt totally. Then cover with the blanket. Investigation: ECG monitoring. Urinary and gastric catheter: v-important. Good urinary out put means proper fluid infusion. – Monitoring. • X-ray: vital x-ray only. (Pelvis, chest, cervical). • Diagnostic studies. - Secondary survey: full history and exam and investigation. - Tertiary survey: must be seen by consultant next morning. - Re-evaluation. – Definitive care: refer him to specialist. Don’t forget: – Records. – Consent for treatment. – Forensic evidence. (Bullet, knife, clothes). – Assume pt has cervical injury. – Finally don’t be panic… ANATOMY AND PHYSIOLOGY OF THE CARDIOVASCULAR SYSTEM ANATOMY OF THE CARDIOVASCULAR SYSTEM: - It is composed of: The Heart The blood vessels Arteries Capillaries Veins THE HEART: Fist-sized organ situated in the center of the chest, between the sternum and the spine and above the diaphragm. It is surrounded by the lungs except in small area in front of the heart known as the bare area and the area against the spine. - It has a hollow tough muscular wall surrounded by the pericardium. - It is divided into right and left side and each side has 2 chambers, right atrium and ventricle and left atrium and ventricle. THE VASCULAR SYSTEM It comprises: Ateries Thick-walled, carrying blood from the heart under high pressure. Capillaries Thin network of one cell layer. Veins Thin-walled vessels that carry blood under low the heart. pressure back to Pulmonary Circulation Pulmonary Circulation Systemic Circulation Aorta and Major Arteries Arteries of the Head and Neck Arteries of the Brain PHYSIOLOGY OF THE HEART 1- Heart pumps blood from the rt. ventricle into the pulmonary artery to the lungs to purify the blood and from the left ventricle into the aorta to distribute blood to the rest of the body. 2- Arteries carry blood away from the heart 3- veins carry blood back to the heart 4- Exchange of gases takes place in the capillary system throughout the body. Functions To purify the blood through the pulmonary capillary system To provide oxygenated blood to all tissues, through the systemic capillary system. The heart beats 60-80 beats per minute during rest. The amount of blood pumped by a single beat and known as the stroke volume is ~70ml. The heart pumps ~5 lit/min.Cardiac output is equal to stroke volume multiplied by heart beats/min. That is to say 70x70=4900 (5 liters/min). The heart can beat faster, up to 180-200 beats/min during exercise, so it is capable of pumping up to 35 lit. per minute. Blood supply to the Myocardium: Two coronary arteries, right and left, originate from the first part of the aorta. They are divided into several branches which encircles the heart to supply the myocardium. The coronary arteries are end arteries. There is no venous coronary artery. Extrinsic Innervation of the Heart The heart is stimulated by the sympathetic cardioacceleratory center The heart is inhibited by the parasympathetic cardioinhibitory center Conduction system of the Heart The contraction is known as systole and is followed by a relaxation period known as diastole. During systole the heart pump blood into the vascular system, while during diastole the heart is relaxed and receives venous return and recharges Electrocardiography (ECG) Cardiac Cycle Cardiac cycle refers to all events associated with blood flow through the heart – Systole – contraction of heart muscle – Diastole – relaxation of heart muscle Phases of the Cardiac Cycle Ventricular filling – mid-to-late diastole – Heart blood pressure is low as blood enters atria and flows into ventricles. – AV valves are open, then atrial systole occurs. Phases of the Cardiac Cycle Ventricular systole – Atria relax – Rising ventricular pressure results in closing of AV valves – Isovolumetric contraction phase – Ventricular ejection phase opens semilunar valves Phases of the Cardiac Cycle Isovolumetric relaxation – early diastole – Ventricles relax – Back-flow of blood in aorta and pulmonary trunk closes semilunar valves Dicrotic notch – brief rise in aortic pressure caused by backflow of blood rebounding off semilunar valves. Phases of the Cardiac Cycle Figure 17.18a Phases of the Cardiac Cycle Heart Sounds Heart sounds (lub-dup) are associated with closing of heart valves At Rest Heart beat/minute = 70x1 = 70 Heart beat/hour = 70x60 = 4,200 Heart beat/day = 4200x24 = 100,800 Heart beat/year = 100,800x365 = 36,792,00 Volume pumped/min = 5lit Volume pumped/hour = 5x60 = 300 lit Volume pumped/day =300x24 = 7200 lit Volume pumped/year = 7200x365 lit =2,628,000lit THE RESPIRATORY SYSTEM The respiratory system has 4 components – The Airway – The neuromuscular system – The Alveoli – The vascular system, arteries, capillaries & veins 1. THE AIRWAY Upper airway -Nose and mouth -Pharynx -Larynx Lower airway -Trachea -Bronchi (right and left) -Bronchioles 2. NEUROMUSCULAR SYSTEM Comprises of: Respiratory centre in the brain Nerves Muscles of respiration These are: –Diaphragm –Intercostal muscles –Some muscles in the neck and shoulder girdle Chest cage: protects the lungs and the heart –Spine at the back –Sternum in front –ribs around A- Respiratory centre in the brain &Nerves Muscles of respiration Chest cage Chest cage 3. THE ALVEOLI Minute air sacs, millions in number. They are made of a very delicate thin membrane of one cell layer forming a fine network. The capillaries are on the outer side of the alveoli where exchange of gases is carried out. 4. PULMONARY VESSELS Arteries carry dark blood with low oxygen levels from the heart to the fine network of capillaries where O2 is picked-up by the blood and CO2 is expelled in to the alveoli. The oxygenated blood is the carried out to the left side of the heart by the veins. PHYSIOLOGY OF RESPIRATION: The function of the respiratory system is to pick-up oxygen from the air and expel carbon dioxide into the air. Metabolism is a continuous process which needs oxygen to function and as a result of this process, carbon dioxide is produced. The Cardiovascular system transports oxygen from the lungs to the cells and transports carbon dioxide from the cells to the lungs for elimination. The breathing mechanism is controlled and influenced by the respiratory centre in the brain and primarily the rate and depth of breathing is stimulated by carbon dioxide in the arterial blood. As the level rises, the respiratory centre sends a continuous parade of signals via the nerves to This will result in an increasing rate and depth of breathing until the level of carbon dioxide falls, then the breathing rate and depth are returned to normal. This is known as feedback mechanism between carbon dioxide level and the rate and depth of breathing. Inspired Air Expired O2 21% 16% CO2 0.03% 4% N2 79% 79% Humidity Less More During respiration, 5% of oxygen passes from atmospheric air into the blood through alveolar and capillary walls and 4% of carbon dioxide is eliminated from the blood into the expired air. Inspiration is an active process while expiration is a passive process.