 Dr: Al-Maredi Nada

Nasser Mohammed
Teaching assistant
in Anesthesia
department faculty
of Health sciences
Islamic University in
Uganda kampala
campus
 Way of teaching
Undertaking initial assessment and management (EM I)
for 3th year Semester 1
General ER
Advanced Lectures
Seminars
Case presentation
Grand rounds

2
 AIME OF COURSE

 Utilizethe emergency medicine

approach to the undifferentiated
patient to prioritize tasks using
effective history taking and
examination techniques.
Recommended Books and
References for reading

 Tintinalli's Emergency Medicine

last edition.
 Atlas of emergency medicine, last

edition.
 Emergency medicine procedures,

last edition
 Methods of Trainees Evaluation
Type Method Score Total Required
%

Formative Medical ethics 20% 100% 80%

Evaluation
Attendance 30%

Periodic MCQ exams, OSCE 30%

and Quizzes
Log book (appendix) 20%

Summati Total formative evaluation score 30% 100% 65%

ve
Evaluatio Final written exam consisted of 30%
n 100 emergency cases in the form
of MCQ.
Final practical and OSCE exam 20%
Final oral exam 20%
 INTRODUCTION OF Emergency medicine

Emergency medicine is an integral and

important part of the healthcare
system.
his principal mission
is to prevent, diagnose and manage
acute and urgent aspects of illness and
injury affecting patients of all age
groups with a full spectrum of
undifferentiated physical and
behavioral disorders.
Why emergency
medicine is
important
Increase density of population that
mandates developed health systems.

Diversity of pat's complaints, age and

presentation.

Increase incidence of disaster events, and

increase of risks related disaster like climate

changes, increased uses of more fatal
agents in war.
_to decrease disease related disability in
community.
Content of lecture
_Definition of the emergency
medicine
-brief hx about scope

emergency medicine
 Emergency First aid
Emergency medical services
Approach to the emergency

medicine
In the conceptions of African
federation for emergency medicine
Pre-arrival preparation
Rapid handover
Primary survey
Investigations
Secondary survey
Disposition
Defenition:
* Emergency Medicine as defined by
the International Federation for
Emergency Medicine in 1991 as "A field
of practice based on the knowledge and
skills required for the prevention,
diagnosis and management of acute and
urgent aspects of illness and injury
affecting patients of all age groups.
* with a full spectrum of
undifferentiated physical and
behavioural disorders.
* It further encompasses an
understanding of the development of
 Brief history of an emergency
medicine

The term “emergency,” first

used 1630 and in the derived from
the Latin word emergere, meaning
unforeseen events that require
immediate attention

The term “emergency medicine”

can be traced to the French
Revolution (1789–1799
in1792 Dominique Jean Larrey,
witnessed great mobility of the horse
artillery and then suggested that
General Adam Philippe de Custine have
the medical staff use this method to
speed up transport of the wounded

In 1797 during the first Italian

campaign, Larrey created a complete
rescue system with an active medical
team in the battlefield.
Larrey has often been referred to as
“the father of emergency medical
In 1961, es Dr James DeWitt Mills
established 24/7 emergency care at
Alexandria Hospital in Alexandria, Virginia;
it was later known as the Alexandria Plan.

 In 1970, the University of Cincinnati

launched the first emergency resident
physician program in the world.

In 1971, the University of Southern

California became the first American
medical school to establish a department
of emergency medicine.
In 1-1-1991, arab-board specialition
in emergency medicine has been
approved

while emergency medicine can only

be traced back to 50 years ago, making
it the most recently developed major
field in medicine. Before the 1960s,
staff in hospital emergency
departments usually worked in rotation
with family doctors, general surgeons,
physicians, and other specialists
 Scopes of an emergency
medicine
Emergency medicine encompasses :
Clinical emergency care
-hospital care
-pre-hospital care, tactical medicine, and
military medicine
 Management aspect of emergency
medicine:
-planning, oversight, and medical
direction for community
emergency medical response, medical control,
-disaster preparedness.
-mass gathering planning.
 Disaster preparedness:

 _ definition and examples

 _types

 _ roles of en emergency
physicians in disaster
preparedness.
Emergency physicians frequently
have extensive responsibilities for
community and hospital-level
disaster preparedness and response.

Planning for these may include

smaller-scale disasters, or protests
of large scale with anticipated
violence). This
 Disaster definition
The World Health
Organization defines a
disaster as a sudden
ecologic phenomenon of
sufficient magnitude to
require external assistance
 Disaster examples:
attacks of September 11, 2001;
the 2004 Pacific Ocean tsunami;
the 2010 earthquake in Haiti;
 the 2011 earthquake and tsunami in
Japan;
 the 2015 earthquake in Nepal;
and the refugee and civil war crises in
Africa.
Hurricane Katrina in 2005
Flooding in Hadrmoot 2008
Tsunami (SHAHEEN)in Aden , Hadrmoot,
and ALMAHRA 2021
 Types of disaster
According to the causes:
 Natural:
Hurricane, tsunami, earthquake, landslide
 Human made :armed conflict, industrial
accidents
 Complex disaster: where there is total or
considerable breakdown of authority resulting
from internal or external conflict and which
requires an international response
According to the location:
 Internal
 external.
THE AIMS OF EMERGENCY FIRST AID ARE:

• To preserve life,
 • To prevent the worsening of

one’s medical
 condition,
 • To promote recovery, and
 • To help to ensure safe

transportation to the
 nearest healthcare facility.
PURPOSE OF EMERGENCY
FIRST AID
DO’S AND DON’T
PRINCIPLES OF EMERGENCY
FIRST AID(4C’S)
 OBJECTIVES OF EMERGENCY
FIRST AID
 To understand your own abilities and
limitations.
 ■ To stay safe and calm at all times.
 ■ To assess a situation quickly and calmly and

summon the
 appropriate help if necessary.
 ■ To assist the casualty and provide the necessary

treatment, with
 the help of others if possible.
 ■ To pass on relevant information to the emergency

services, or
 to the person who takes responsibility for the casualty.
 ■ To be aware of your own needs.
Emergen
cy
 THE EMERGENCY FIRST AIDER MUST HAVE
A first aider is the term describing any person who has
received a certificate from an authorized training body
indicating that he or she is qualified to render first aid.
First aid certifications issued by St. John Ambulance
Association and the Indian Red Cross Society are
awarded to candidates who have attended a course of
theoretical and practical work and who have passed a
professionally supervised examination and medical,
paramedical profession person from recognized
board/university/council.
 EMERGENCY FIRST AID
PRIORITIES(APPC)
 • Assess a situation quickly and calmly.
 • Protect yourself and any casualties from
danger—never put yourself
 at risk .
 • Prevent cross-contamination between yourself
and the casualty as
 best as possible .
 • Comfort and reassure casualties
 • Assess the casualty: identify, as best as you
can, the injury or nature
 of illness affecting a casualty .
 • Give early treatment, and treat the casualties
with the most serious
 (life-threatening) conditions first.
•Arrange for appropriate help: call
911 for emergency help if you
suspect serious injury or illness; take
or send the casualty to the
hospital; transfer him into the care
of a healthcare professional, or to
a higher level of medical care. Stay
with a casualty until care is
available.
IMPORTANCE OF EMERGENCY FIRST AID
ACTION PLAN IN
EMERGENCY
SKILLS OF A FIRST AIDER
KEY SKILLS TO EMERGENCY FIRST
AID(ABCD)
 First aider are taught to focus on
the ABC of
 first aid before giving additional

treatment:
 – Airway
 – Breathing
 – Circulation
 • Some instructor add a fourth step

of D for
 – Deadly bleeds or defibrillation.
 CONTINUED

 SAME ORDER OF PRIRIOTY USING

THE 3 BS:
 • Breathing
 • Bleeding
 • Bones.
PRINCIPLES OF EMERGENCY
FIRST AID
GOLDEN RULES FOR EMERGENCY
FIRST AID
ROLE OF EMERGENCY FIRST
AIDER
 Remember PACT
• P - Protect
• A - Assess
• C - Care
• T - Transport-Triage
ROLE OF EMERGENCY FIRST AIDER
RESPONSIBILITY OF
EMERGENCY FIRST AIDER
 Pre-arrival preparation
 Ideally,
the team is notified prior to arrival of the
trauma patient and equipment and personnel
prepared.
 Ideal trauma team
 Medical trauma team leader
◦Emergency physician or trauma surgeon
 Dedicated airway doctor
◦Emergency physician or anesthesiologist
 Procedure doctor
◦Often emergency or trauma trainee physician
 Trauma nurse leader (scribes)
 Airway nurse or respiratory technician
 Circulation nurse
 Radiographer
 Pre-arrival preparation
 Ensure
that you have:
◦Equipment checked and ready
◦People prepared with PPE
 Rapid handover
Performed while starting primary survey:
 DeMIST
◦Demographics: age, where did injury occur
◦Mechanism of injury: type and energy pattern
◦Injuries identified by EMS/bystanders
◦Signs or symptoms from EMS/bystanders
◦Treatment provided, if any
 High risk mechanisms
High speed collision
Pedestrian vs. motor vehicle
Fall from >3 meters
Serious penetrating injuries
Evisceration
Explosion
Major limb amputation
Severe burns
 High risk trauma patients
Signs

◦RR >30 per minute

◦SBP <100 (adult)
◦GCS <14
Treatment

◦Assisted ventilation
◦Chest compressions
 Primary survey
 Initialassessment and management of all
immediately life-threatening injuries
 Assessed and managed in order of priority.
 Once identified, life-threatening issues

must be dealt with before proceeding to

next step.
 At any point, if the patient’s condition

deteriorates, repeat the primary survey.

 Primary survey
 ABCs: assess, intervene, reassess
Airway maintenance with cervical spine
immobilisation
Greet the patient. Is he speaking
normally?
◦If the patient is talking
normally, the airway is patent.
oAbnormal voice requires
further evaluation.
Airway maintenance with cervical spine
immobilisation
• Signs of airway obstruction
–Agitation
–Hypoxia
–Obtundation
–Cyanosis
–Accessory muscle use or visible
obstruction (e.g. vomit or blood in
the mouth)
–Abnormal airway sounds, including
stridor and gurgling
 Airway assessment
• Assume unstable cervical spine
injury until proven otherwise
• C-spine stabilisation
–hard collar
–sandbags/blanket roll secured
with two tapes
• Manual in-line immobilisation,
especially during airway
procedures
Threatened airway
Threatened airway
 Airway: management
 Immediate airway management may
include
◦Jaw thrust
◦Suction
oUse Yankauer rigid probe gently, do not
cause further bleeding or trauma
◦Oral or nasal airway placement
oOral airway, nasal trumpet, LMA
◦Definitive airway
oEndotracheal or surgical airway
 Airway: management
 Endotracheal intubation indications
◦A: Threatened airway
oairway burns, bilateral mandibular fractures,
laryngeal oedema, tracheal injury, expanding
neck haematoma or airway haemorrhage
◦B: Respiratory failure
oflail chest, inhalational injury
◦C: Severe shock
oto optimise oxygenation and reduce work of
breathing
◦D: Inability to protect a patent airway
opatients with GCS < 9 or requiring sedation
 Airway: management
 Open: Jaw thrust and suction oropharynx
 Use Magill’s forceps to remove large foreign bodies

and assist with intubation

 Airway: management
 Non-Definitive airway
devices
 Definitive airway
 Intubation
 Surgical airway (cricothyroidotomy)
 Principle:
Breathing
◦Administer high flow O2 to keep sats >93%, and
manage immediately life-threatening injuries:
oTension pneumothorax
oOpen pneumothorax
oFlail chest
oSevere lung contusion or inhalational injury,
aspiration after head injury
oMassive haemothorax
oDiaphragm rupture
oMajor airway injury
 Breathing assessment
 Vitalsigns
◦Tachycardia, tachypnea, hypoxia,
hypotension
 Look

◦Respiratory distress
◦Cyanosis
◦Open “sucking” chest wound
 Breathing assessment
 Listen
◦Present breath sounds equal bilaterally?
 Palpate
◦Tracheal position
◦Crepitus over neck or chest
◦Percuss for hyper-resonance or dullness
◦Flail segment with paradoxical movement
olocalised portion of chest wall moves in
opposite direction during spontaneous
respiration
 Tension pneumothorax
 Assessment
◦Respiratory distress
◦Unilateral decreased breath sounds
◦Hypoxia
◦Tachycardia
◦Hypotension
◦Cyanosis
◦Tracheal deviation towards unaffected side
Tension pneumothorax
 Management

◦Immediate needle decompression

oTraditionally, 2nd intercostal space, mid-
clavicular line
oIncreasing evidence to support 5th ICS,
mid-axillary line
◦Must be followed by formal chest tube
placement
Pneumothorax

Yellow line – collapsed

lung
 Open pneumothorax
Assessment
◦Respiratory distress
◦Hypoxia
◦Tachycardia
◦Cyanosis
◦Open ‘sucking’ chest wound
 Open pneumothorax
 Management

◦Place occlusive ‘one-way valve’ dressing

over open sucking wounds
◦Occlusive dressing secured on three sides
and not adherent to chest wall
 Allows outflow of air from pleural space,
but not inflow.
 Followed by placement of chest tube, then
closure of the original wound.
 Flail chest
 Flail segment: localised portion of chest wall
moving in opposite direction from remainder
of chest during spontaneous respiration
 Assessment

◦Respiratory distress
◦Hypoxia
◦Tachycardia
◦Cyanosis
◦Flail segment
 Flail chest
 Management

◦High-flow O2
◦Consider early positive pressure ventilation
◦Place chest tube prior to PPV if any concern for
pneumothorax
Flail chest/ Lung contusion

Flail segment on CXR; occult PTX on CT

chest with posterior lung contusion
noted (arrow)
 Circulation
• Principle
–Identify shock
–Determine cause of shock
–Fix that problem

• Most common cause of shock is

haemorrhage

Treatment of bleeding is to find

and stop the bleeding!
 Circulation
 Assessment
◦Tachycardia
◦Hypotension
◦Sluggish capillary refill
◦Altered mental status
◦Signs specific to the source of haemorrhage

Absence of hypotension does not exclude

shock! Hypotension is a late finding.
Circulation
Severity of shock
 Circulation
 Management

◦High-flow O2
◦2 large-bore IV lines
◦20ml/kg IV bolus crystalloid fluid
oReassess frequently during bolus
oPatients without evidence shock can
be given smaller amounts of fluid
Stop the [Link] IV access.
Give fluids.
Stop the bleeding. Gain IV access. Give
fluids.
 Circulation
 Persistence of shock after 2 IV boluses
(40ml/kg IVF total)
2 units packed red cells immediately
Identify source of bleeding if have not
Emergent Trauma Surgery consult for
theatre
Goal [Link] PRBC:platelet:factor if requires
further transfusion
 Blood replacement in trauma
 Massive transfusion
◦Risk for coagulopathy
oIf transfusing multiple units PRBCs in
trauma patient, strongly consider FFP and
platelets in [Link] ratio
oHypothermia contributes to coagulopathy
• Keep patient warm!
◦Risk for citrate toxicity (hypocalcaemia)
oMonitor for symptoms hypocalcaemia
oTypically not seen until >8 units transfused
 Blood replacement in trauma
 Massive transfusion
◦Risk for hypothermia
oChildren at highest risk
oUse warmer if available
◦Risk for hyperkalaemia
oRisk highest with older blood
oFollow K+ closely
 Blood replacement in trauma
 Rh status
◦Rh+ blood may be transfused to Rh- recipients
if Rh- blood unavailable
◦Risk is haemolytic reaction in future
transfusions.
◦In emergency, this risk is justified.
◦Children and women of child-bearing age
should be prioritised for Rh- blood.
 If unavailable, must give Rho(D) immune
globulin after Rh(+) transfusion
 Permissive hypotension
 Trauma literature unclear as to exact
blood pressure parameters
 Possible benefit to “permissive

hypotension” in penetrating trauma

 Critical to AVOID hypotension in blunt

trauma and head injury

 Permissive hypotension
 Suggestedresuscitation goals
◦Penetrating trauma
oSBP ≥90
◦Head injury
oSBP ≥120
 Disability
 Rapidly assess head or spinal injury
 Record blood glucose

◦Usually raised in acute trauma, but

may be decreased by alcohol
 Glasgow coma scale
 Pupil size and reactivity
 Disability
 Basicneurologic exam (extremity
movements)
◦Lateralising signs
oHemiparesis
oPara- or tetraparesis
 Consider neurogenic shock if persistent

hypotension despite adequate resuscitation.

◦Must rule out haemorrhagic shock!
 Disability
 Glasgow Coma Scale (GCS) AVPU
Exposure and environmental control
 The patient must be completely undressed
◦Cut off clothes
◦Remove underwear and rings, chains, jewellery.
 Keep the patient warm and dry

◦Hypothermia causes coagulopathy

 Log-roll to examine back and do PR exam

◦PR required to exclude high-riding prostate in

males with pelvic fracture prior to urine
catheter placement
 Investigations
 Done in parallel with primary survey
◦ CXR
 AP-supine is adequate
◦ Pelvic XR
 only essential in blunt trauma
◦ FAST ultrasound
Fluid
Liver

Kidney
 Cervical spine clearance
• Maintain c-spine immobilisation until definitive clearance.
• Cannot clear by exam or lateral x-rays if patient is altered
or in poly-trauma
• If unable to clear, consider CT c-spine.
• If unable to obtain CT c-spine, keep immobilised and
consult Neurosurgery.
Cervical spine clearance
 SECONDARY SURVEY
 History in detail
◦AMPLE
 Allergies, medications, prior
medical/surgical history, last mealtime,
events leading to current admission
 Head-to-toe examination

◦Identify all injuries, from minor to major,

to avoid missed-injury morbidity
EMERGENCY FIRST AID IN MEDICAL
EMERGENCY

• ACUTE MYOCARDIAL INFARCTION

• Bleeding
• BRONCHIAL ASTHMA
• Asphyxia
• Choking
• Shock
• Drawing
• Suffocation
•Wounds
Bend the person over at the waist to
face the ground. Strike five separate
times between the person's
shoulder blades with the heel of
your hand. Give five abdominal
thrusts. If back blows don't remove
the stuck object, give five
abdominal thrusts, also known as
the Heimlich maneuver
Position one clenched fist
above the navel and below the
rib cage. Grasp your fist with
your other hand. Pull the
clenched fist sharply and
directly backward and upward
under the rib cage 6 to 10
times quickly. If the person is
obese or in late pregnancy,
give chest compressions
FIRST AID MEASURE
Disability (neurologic evaluation)
THANK YOU