Transcript Disease Identification and Injury Prevention

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
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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
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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:
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III.
Potential threats to life or function
Time to Physician: < 15 minutes
Severe trauma, altered LOC, Stroke, overdose, chest pain.
Urgent:
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IV.
Potential progression into serious problems.
Time to Physician: < 30 mins
Moderate asthma, moderate trauma, vaginal bleeding
Semi Urgent :
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V.
Potential for deterioration
Time to Physician: < 60 mins
Non urgent:
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Acute but not urgent or part of chronic problem, can be seen at other areas.
Minor Lacerations, sore throat, chronic mild abdominal pain
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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
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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:
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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.
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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:
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Airway
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Breathing
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Circulation
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Drugs:
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Draw blood:
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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
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Decontamination:
1.
Ocular:
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2.
Dermal:
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3.
Flush eyes with saline
Remove contaminated clothing
Brush off
Irrigate skin
Gastro-intestinal:
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Activated charcoal:
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May Prevent /delay absorption of some drugs/toxins
Almost always indicated
Naso/oro-gastric Lavage
Bowel Irrigation:
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Recent ingestions 4-6 hrs
Awake alert patient
500 cc NS Children / 2000cc adults
Orally / Nasogastric tube
Contraindications…?
Bites & Stings
Types:
• Mammals
• Human
• Canines
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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”