Life Threatening Commonly Seen Medical Conditions in A&E - An Introduction For Paramedics and...

Life Threatening Conditions

K.S. CHEW (MD, MMED)

Emergency Medicine DepartmentSchool of Medical Sciences

Universiti Sains Malaysia

Life Threatening Conditions are conditions that compromise the

AIRWAYBREATHING

CIRCULATION

Overview

• Examples of conditions threatening to the:• Airway

– Trauma: Facial trauma, facial burns– Non-trauma: anaphylaxis, asthma, foreign bodies

airway obstruction• Breathing• Circulation

Overview

• Examples of conditions threatening to the:• Airway• Breathing

– Trauma: Chest trauma – tension pneumothorax, open pneumothorax, flail chest

– Non-trauma: asthma, pulmonary embolism• Circulation

Overview

• Examples of conditions threatening to the:• Circulation

– Trauma: Cardiac tamponande– Non-trauma: acute myocardial infarction, acute

thoracic dissection

AIRWAY

Why Airway Management?

• Maintain a patent airway• Facilitate mechanical ventilation in respiratory

failure• Optimize pulmonary gas exchange; thus

prevent hypoxic damage to the brain and other vital organs

• Reduce risk of aspiration• Reduce risk of nosocomial pneumonia and

assist in removal of bronchial secretions

0 – 2 min Cardiac Irritability

0 – 4 min Brain damage not likely

Effects of Hypoxia

4 - 6 min - brain damage possible6 - 10 min - brain damage very likely

More than 10 min - irreversible brain damage

Effects of Head-Tilt Chin-Lift

Alignment of oral axis, pharyngeal axis and tracheal axis

Importance of Opening the Airway

The most common cause of ventilation difficulty during resuscitation is an improperly opened airway

(AHA Guidelines 2005)

Opening the Airway

• Lay Rescuer – open the airway using head-tilt chin lift maneuver for non-trauma victims and gentle chin lift for trauma. Jaw thrust no longer recommended because it is difficult to learn and perform, often not effective.

• Health Care Provider – Head tilt-chin lift if not trauma. If trauma, apply manual in-line stabilization and jaw thrust.

Opening the Airway

• If airway obstruction persists despite jaw thrust, attempt head tilt-chin lift even in trauma

• This is because maintaining a patent airway and providing adequate ventilation is a priority in CPR (AHA Guidelines 2005)

• Furthermore, this complication of damaging the cervical cord has not be documented and the relative risk is unknown (ERC Guidelines 2005)

Effects of Head-Tilt Chin-Lift

Alignment of oral axis, pharyngeal axis and tracheal axis

Remember to protect the cervical spine in cases of trauma

Use bags or pillows, etc, to immobilize the cervical spine

OROPHARYNGEAL AIRWAYS

Oropharyngeal Airways

• OPAs are sized by length in centimeters, and are available in sizes for all ages.

• A typical adult female will take an 8-cm OPA, and an adult male, 9 or 10 cm.

How To Perform?

• In adults – insert ‘upside down’ until tip touch hard palate and then rotate 180° before inserting further

• Can also insert directly (non-inverted way) with use of tongue depressor

• This is preferred in children because of risk of trauma to delicate soft tissue

Size of OPA can be estimated from the edge of ear lobe (angle of mandible) to the corner of mouth (incisor teeth)

Emergency Care When The Victim is Choking

Universal Sign of Choking

Performing Heimlich Maneuver (abdominal thrust)

only if the upper airway obstruction is complete or

near total complete

Observe is victim is whether cyanosed, or if his voice

becomes muffled or his cough becomes ineffective

Position to place your fist between the xiphoid process and the umbilicus

Use one hand as the fist. The other hand to grasp the fist and BE PURPOSEFUL and DELIBERATE. Thrust upwards and inwards.

If, at any time, the victim collapses, lie him flat and proceed as you would in BLS sequence.

Open the airway to see if foreign body is present; if no, attempt rescue breaths (five attempts for two effective breaths) and start chest compression if pulse not present or no signs of life.

BREATHING

Examples of Life Threatening Trauma Conditions to the

Breathing

Initial Assessment/Management in TRAUMA

• Primary Survey• Identifies most life-threatening injuries• Resuscitation• Airway control• Ensure oxygenation / ventilation• Needle / tube thoracostomy

Life Threatening Conditions In Trauma

Primary Survey• Airway obstruction• Tension pneumothorax• Open pneumothorax• Flail chest• Massive hemothorax• Cardiac tamponade

Tension Pneumothorax: Etiology• Parenchymal and/or chest-wall

injuries• Air enters pleural space with no exit• Positive pressure ventilation

– Collapse of affected lung– Venous return– Ventilation of opposite lung

Tension Pneumothorax

Tension Pneumothorax: Signs / Symptoms• Respiratory distress• Distended neck veins• Unilateral in breath sounds• Hyperresonance• Cyanosis, late

Tension Pneumothorax

Tension Pneumothorax• Immediate

decompression• Clinical diagnosis, not

by x-ray

Tension Pneumothorax

Asthmatic Attack

Asthmatic Attack

• Asthma sufferers have very sensitive airways, and when they are exposed to certain triggers, their airways narrow making it difficult for them to breathe.

• An asthma attack can take anything from a few minutes to a few days to develop

Signs and Symptoms

• pale, cool, clammy skin• coughing, especially at night• shortness of breath – using all the chest and

diaphragm muscles to breathe• ‘sucking in’ of the throat and rib muscles• Severe chest tightness• wheezing – a high pitched raspy sound

Signs and Symptoms

• cyanosis around the lips (bluish colour)• anxiety and distress• exhaustion• rapid, weak pulse• little or no improvement after using reliever

medication (e.g. Bricanyl or Ventolin)• severe asthma attack: collapse – leading to

eventual respiratory arrest

With spacer• shake inhaler and insert mouthpiece into

spacer• place spacer mouthpiece in casualty’s mouth

and give 4 separate puffs of a blue/grey reliever puffer

First Responder Care

First Responder Care

Contd…

• give 1 puff at a time• ask the casualty to breathe in and out

normally 4 times after each puff• wait 4 minutes. If there is little or no

improvement, repeat the above sequence

Without spacer• shake inhaler• place mouthpiece in casualty’s mouth. • Give 1 puff as the person inhales slowly and

steadily

First Responder Care

contd…

• Ask the casualty to hold that breath for 4 seconds, then take 4 normal breaths

• Repeat until up to 4 puffs have been given• Wait 4 minutes. If there is little or no

improvement, repeat the above sequence

First Responder Care

CIRCULATION

Heart Attack

The Heart

• The normal human heart is a strong, muscular pump a little larger than a fist.

• Each day an average heart “beats” (expands and contracts) 100,000 times and pumps about 2,000 gallons of blood.

• In a 70-year lifetime, an average human heart beats more than 2.5 billion times.

In Myocardial Infarction, time lost is myocardium

lost!!

EMS Transport

Onset of symptoms of

STEMI

9-1-1EMS

Dispatch

EMS on-scene• Encourage 12-lead ECGs.• Consider prehospital fibrinolytic if

capable and EMS-to-needle within 30 min.

GOALSPCI

capable

Not PCIcapable

Hospital fibrinolysis:

Door-to-Needle

within 30 min.

EMS Triage Plan

Inter-HospitalTransfer

Golden Hour = first 60 min. Total ischemic time: within 120 min.

Patient EMS Prehospital fibrinolysisEMS-to-needlewithin 30 min.

EMS transportEMS-to-balloon within 90 min.

Patient self-transport Hospital door-to-balloon

within 90 min.Dispatch

1 min.

5 min.

8 min.

Pre-hospital Care of MI

Typical Chest Pain

Hollywood Heart Attack

Remember

With heart attack, every minute counts. If the warning signs are present, do not waste vital moments wondering whether it is a heart attack or not. Take immediate action!

First Responder Care to Patient with MI

• Recognize and Call (MOST IMPORTANT!)• Rest the casualty in a position of comfort,

usually sitting• Assist the casualty to take their medication

(nitroglycerine tablets)

First Responder Care to Patient with MI

• If conscious, give casualty 1/2 an aspirin tablet and have them chew it slowly, unless it is known that the person has been advised not to take aspirin

• Reassurance• Stay with the casualty and observe him

Pads Position

Posterior Position

Defibrillation Cardioversion

Not synchronised Synchronised on the R wave

For cardiac arrestFor periarrest

tachyarrhythmias (unstable)

Higher energy joules Lower energy joules

No escalating energy for next shock

Escalate for next shock (100 - 200 - 300 - 360J)