1. Disease Identification and Injury Prevention Accident & Emergency Module Lecture II Norah Al-Khathlan MD

2. 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.

3. 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.

4. 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.A chief complaint and a brief focused history relevant to the chief complaint 2.A complete and accurate set of vital signs with critical interpretation 3.An opportunity to visualized, auscultate and touch the patient

5. 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 1 st not costochondritis, fever in neonates ---neonatal sepsis not URTI)

6. 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.

7. 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

8. 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

9. CTAS 5 Canadian Triage & Acuity Score I.Resuscitation: Life/Function threatening eg: code, arrest, shock, coma Time to Physician : Immediate II.Emergent: Potential threats to life or function Time to Physician: < 15 minutes Severe trauma, altered LOC, Stroke, overdose, chest pain. III.Urgent: Potential progression into serious problems. Time to Physician: < 30 mins Moderate asthma, moderate trauma, vaginal bleeding IV.Semi Urgent : Potential for deterioration Time to Physician: < 60 mins V.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

10. 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

11. 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)

12. 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!

13. 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!

14. III- Prevention of Injury “Prevention is the vaccine for the disease of injury.” Host AGENTA causal relationship! Environment

15. Prevention of Injury The 4 E’s: Education Enactment/Enforcement Engineering Economic incentives and penalties

16. Prevention of Injury Categories of injury prevention: Primary prevention: Eliminate the event Secondary prevention: Diminish effect Tertiary prevention: Improve outcomes

17. 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.

18. 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.”

19. 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

20. Poisoning Examples: ASA Acetaminophen TCA Narcotics & drugs of abuse Benzodiazepines Iron supplements Alcohol

21. Poisoning ABC’s of Toxicology: Airway Breathing Circulation Drugs: Resuscitation medications if needed Universal antidotes Draw blood: chemistry, coagulation, blood gases, drug levels Decontaminate Expose / Examine Full vitals / Foley / Monitoring Give specific antidotes / treatment

22. Universal Antidotes: 1.Oxygen 2.Glucose 3.Naloxone “Narcan” 4.Thiamine Poisoning

23. Decontamination: 1.Ocular: –Flush eyes with saline 2.Dermal: –Remove contaminated clothing –Brush off –Irrigate skin 3.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…?

24. Bites & Stings Types: Mammals Human Canines Snakes Scorpions Bees Others

25. Bites & Stings Clinical Presentation: Pain Wounds Swelling Bleeding Neurological Infection Shock

26. 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

27. 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”