Disease Identification and Injury Prevention

1. Disease IdentificationandInjury Prevention Accident & Emergency Module Lecture II Norah Al-Khathlan MD

2. Objectives At the end of this lecture you should be able to: • Identify age specific disease presentation to emergency room. • Define injury. • Recognize the importance of injury prevention • 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 ) • 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

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 1st 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 5Canadian Triage & Acuity Score • Resuscitation: • Life/Function threatening eg: code, arrest, shock, coma • Time to Physician: Immediate • Emergent: • Potential threats to life or function • Time to Physician: < 15 minutes • Severe trauma, altered LOC, Stroke, overdose, chest pain. • Urgent: • Potential progression into serious problems. • Time to Physician: < 30 mins • Moderate asthma, moderate trauma, vaginal bleeding • Semi Urgent : • Potential for deterioration • Time to Physician: < 60 mins • 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 • AGENT A 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. Poisoning Universal Antidotes: • Oxygen • Glucose • Naloxone “Narcan” • Thiamine

23. Poisoning • Decontamination: • Ocular: • Flush eyes with saline • Dermal: • Remove contaminated clothing • Brush off • Irrigate skin • 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”