Course Book EMSS04 by Borislav Manev

COURSE BOOK EMSS04 8th to 12th July Hotel Klimetica Ohrid, Macedonia

Course Book EMSS04

Table of CONTENTS Welcome Meet the OC Agenda Nuclear Medicine

3 4 5 8

Acute Metabolic Complication of Diabetes 12 Торакална и Белодробна РТГ Дијагностика 14 Современи аспекти на торакалната хирургија 16

Cervical Smear and Swabs

44 Rectal Examination 51

Современ Третман на Ректалниот Карцином

56 Торакална Дренажа Principles Of

58 Musculoskeletal Injuries

Examination Of CPR: How to save a life 18 70 Patients With An Acute Abdominal Pain Acute Gastrointestinal Bleeding 22 Lumbar Puncture 25

Monitoring Blood Glucose 28 Auscultation of the Heart and Lungs 30 Venipuncture 37

”To be part of a big family is to call oneself the richest person in the world.” Design And Editing

Demijan Hadzi Angelkovski

Review Board

Gordana Georgieva Goran Stevanovski Bogdan Kovachev

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Welcome...

edicine. For some people it is just a job, for others it is a profession. For us, enthusiastic medical students and young doctors in EMSA it is far more than that. Medicine is a lifestyle, a way of life that we have accepted and has become a huge part of us and our personality. It is not something that starts with our morning lectures or something that goes away at the end of the semester. It combines our hopes, dreams and the people that surround us. This is why we organize our fourth annual Summer School for Emergency Medicine, so that we can continue the learning process during the summer break. Emergency Medicine is an integrative part of medicine that finds its place in every medical field and specialty and even though some of us still donâ&#x20AC;&#x2122;t know what kind of doctors we want to be, we have to have a practical experience in the basis. In order to keep on top of our game and be up to date with the latest procedures and protocols we give you the great opportunity to gain practical experience from some of the greatest specialists in the fields discussed here in this book. Being a summer season and everything, we have also planned a stunning social program interwoven with amazing people and fellow colleagues from different countries in the world hoping that the friendships created here will last forever and lead to a bigger cooperation between one of the finest future doctors out there. Above all, I want to welcome you to our EMSA family and wish you a successful Summer School. Gordana Georgieva President of EMSA Macedonia

EMSA Macedonia Summer School 2013

Course Book EMSS04

Meet the OC Prof. D-r Daniela Miladinova Vice-Dean for International Collaboration Medical Faculty - Skopje

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AGENDA Notice: this agenda represents only the lectures, workshops and parties. It does not show for free time, breakfast and lunch.

Monday

08.07.2013

08:00 - 17:00

Arrival and Registration

17:00 - 19:00

Ice - Breaking Games

19:00 - 22:00

Gala Opening + Dinner

22:00

Cocktail Party

Tuesday

09.07.2013

10:00 - 13:00

Clinical Practice Workshop

13:00 - 14:00

Nuclear Medicine Lecture

15:00 - 16:00

Laparoscopy Lecture

16:00 - 19:00

CPR Workshop

22:00

Visit to Ohrid

Wednesday

10.07.2013

10:00 - 11:00

Traumatology Lecture

11:30 - 14:30

Suturing and Bandaging Workshop

16:00 - 19:00

Beach Games

22:00

Karaoke Night

Thursday

11.07.2013

10:00 - 13:00

Remedika Sponsored Lecture

13:00 - 14:00

Abdominal Surgury Lecture

15:00 - 17:00

Case Reaports Workshop

17:00 - 18:00

Testing and Evaluation

20:30 - 22:00

Gala Closing and Dinner

22:00

Macedonian Night Party

Friday

12.07.2013

10:00 - 12:00

Triage Simulation

12:00 - 14:00

Visit to Ohrid

14:00 EMSA Macedonia Summer School 2013

Departure from Ohrid

LECTURES

In the pages that follow you will be able to read about the lectures and workshops, in detail, that took place on the EMSS04. They will be a great opportunity for you to learn more, and expand your knowledge.

WORKSHOPS 7

Course Book EMSS04

Nuclear Medicine: Evaluation of Chest Pain in the ER

by Prof. D-r Daniela Miladinova Vice-Dean Medical Faculty - Skopje

Chest pain (CP) is a very common referral to the emergency department (ED). There are many different causes of CP: ● Cardiac (ischemia-including stable and unstable angina, acute heart attack and coronary artery spasm; pericarditis; myocarditis; cardiomyopathy and rare causes such as CA dissection, acute rupture of the heart and valves). ● Pulmonary (pneumonia, pulmonary embolism, pleurits and bleb rupture). Gastrointestinal (reflux, gallstones, esophageal spasm; rupture, strictures or tumours of the esophagus and varicose veins). ● Other potential causes are aortic dissection, back and spine problems ● Psychological causes of CP are panic attacks, stress and anxiety. Nuclear medicine (NM) carries significant importance in the evaluation of the CP of cardiac or pulmonary origin. Commonly used imaging modalities are not always appropriate to confirm or exclude the cause of the CP. Patients referred to an ED within several hours of CP and non-diagnostic ECG could be risk stratified with an injection of 99mTc labelled perfusion tracer (MIBI). Perfusion abnormality is in keeping with myocardial infarction or unstable angina and could be detected prior to elevation of serum enzyme markers. The greater sensitivity of the study is dependent on the period after the beginning of CP. Isotope injection 2h after the symptoms is less reliable and has a high negative predictive value. If the acute study is normal, it can be used as a rest image for comparison with stress image, which follows exercise or pharmacologic stress to exclude underlying coronary artery disease (CAD) in these groups of patients. Pulmonary embolism is the most common referral from ED to NM unit. Also, the single most important application of lung scintigraphy is the evaluation of patients

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EMSA Macedonia with suspected pulmonary embolism (PE). Studies of pulmonary ventilation and perfusion are still based on planar imaging in spite of the introduction of single photon emission tomography (SPECT). These are important for identification and quantification of focal or regional aberrations of organ function. SPECT technique has not been commonly used in pulmonary as in myocardial and brain scintigraphy. Perfusion imaging is based on tracer removal in a single passage through the organ. Intravenously injected 99mTc labeled human albumin macro aggregates (MAA) measuring 10-40m in diameter, results in impaction of the particles in the terminal arterioles and other precapillary vessels. With approximately 200 000 particles given to the subject 0.1% of the total number of arterioles are blocked which allows subsequent gamma camera images of the chest, that show relative pulmonary arterial blood flow. After the impaction most particles will break up within hours due to macrophage activity and then pass through the lungs to be removed from the circulation of the liver and spleen. Full perfusion of the lungs is then restored. Perfusion scintigraphy is safe even in the most severely ill patients. The dose of MAA should be reduced by 50% in pregnant women and children by a factor that relates to body weight. This lowers the radiation burden to acceptable levels even for pregnant women. Perfusion lung scintigraphy is the only applied scintigraphic method during pregnancy and breast feeding. Imaging of ventilation is undertaken with either gases or aerosols. This permits detection of areas of lung with matched (ventilation and perfusion both abnormal) or mismatched (ventilation normal, but perfusion abnormal) perfusion abnormalities. The most commonly used gases are 81mKr and 133Xe, but aerosol imaging is much cheaper and is the technique of choice for ventilation imaging. 81mKr is produced from Rubidium-81 generator is the ideal gas for ventilation studies. The half life of 13 seconds means that Kr decays very quickly within the lungs. The photon energy of 190KeV is ideal for dual imaging because it allows the ventilation imaging to be acquired in the same position after the perfusion imaging with MAA, repeating the procedure after the acquisition of all subsequent perfusion images (AP, PA, LAO, RAO, LPO, RPO). The short half life of the generator, cyclotron production and considerable expense limits its availability and application. 133Xe remains inexpensive and available with half-life of 5.3 days providing conveniently long shelf life, but the low gamma photon energy is a major disadvantage as it provides images with inferior quality and resolution. When Kr is unavailable, 99mTc aerosols provide a ventilation signal with ideal energy to provide six views in order to compare with perfusion images. Aerosols are produced by jet or ultrasonic devices that should produce particles smaller than 1m. Large particles of 5m are inhalable and only those less than 2m will reach peripheral respiratory bronchioles and alveoli. Technegas is an ultra-fine dispersion of small solid 99mTc labeled carbon particles in argon gas produced by a commercial EMSA Macedonia Summer School 2013

Course Book EMSS04 machine and a special heating technique. As 99mTc is the radionuclide for both aerosol ventilation and MAA perfusion studies, simultaneous studies are not possible. Aerosol droplet particles are cleared quite rapidly from the lung, so the delay between ventilation and perfusion study of one hour is usually sufficient to reduce aerosol background activity to acceptable levels. Better time management could be fulfilled using lower ventilation doses with prolonged acquisition protocols rather than increasing the perfusion tracer doses. Application of the MAA through the feet or palm veins could reveal patency of the venous system or diagnose deep vein thrombosis (DVT). As the thrombus grows in size it can occlude the vein locally, but also could propagate along the vein proximally to a larger vein toward the right heart, eventually resulting in PE. DVT and PE are separate but related aspects of the same dynamic process called venous thromboembolism (VTE). Risk factors for VTE are risk factors for thrombosis itself â&#x20AC;&#x201C; stasis of the venous blood, changes to the vessel wall, and changes of the composition of the blood. Vascular injury which increases the risk of platelet thrombus can occur with use of central venous catheters, pacemakers and internal cardiac defibrillators. More commonly found is a genetic or acquired predisposition to thrombus formation (thrombophilia), caused by changes in the composition of blood. Genetic predisposition often leads to increased incidence or recurrent VTE among the family members. Common causes include the presence of factor V Leiden, prothrombin gene mutation, deficiencies in protein C, protein S and antithrombin 3. The acquired risk factors that increase the coagulability of blood and predispose thromb formation are: pregnancy, oral contraceptive pills, hormonal replacement therapy, malignancy and presence of special antibodies associated with arterial or venous thrombosis (lupus anticoagulants and anticardiolipin antibody). Also, environmental risk factors are associated with sluggish blood flow or venous stasis. Multiple risk factors for VTE include immobilization, paralysis, surgery, trauma and wearing leg plaster. Medical illnesses such as cancer, congestive heart failure, chronic obstructive airway disease, diabetes mellitus and inflammatory bowel disease together with increasing age are all very well known risk factors for VTE. Post flight VTE also known as travelerâ&#x20AC;&#x2122;s thrombosis is also important causative factor. Suspicion of pulmonary embolism will arise when the patient is present in ED with CP and breathlessness. The first screening test is quantitative D-dimer measurement for cross-linked fibrin derivatives that are breakdown products of a formed thrombus in the circulation. D-dimers are found high without signs of VTE in patients with myocardial infarction, pneumonia, sepsis, second and third trimester of pregnancy, malignancy, peripheral vascular diseases, serious inflammatory conditions etc. Also, patients with normal D-dimers and high risk for VTE should be investigated further. VQ imaging in combination with radionuclide venography should be used in that situation. Normal perfusion studies exclude clinically significant VTE in the majority of

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EMSA Macedonia cases. Many retrospective studies (including the most important PIOPED) confirmed the number, size and localization of the perfusion defects and their matching with ventilation effects as very important to classify VQ study as high, intermediate and low probability for PE. Duplex ultrasound replaced conventional contrast venography and should be used in cases where a VQ scan is inconclusive. In the past echography was used non-invasively to screen suitable cases for PE. Transthoracic as well as intraesophageal ultrasound could be used. But both methods are with limited accuracy and are not commonly used nowadays with the introduction of CT pulmonary angiography (CTPA). Pulmonary angiography used to be a gold standard, but it has not become widely available because of its invasiveness. CTPA is available in most hospitals even in the developing countries and has evolved in the last two decades into an excellent test for PE. The VQ scan remains very important in the diagnosis of PE, especially in cases with normal chest X-ray where can exclude PE in the majority of low or medium pre-test clinical probability with a significantly lower radiation burden (0.6mSv compared with 8-10mSv from MDCT). Also, VQ scan can correctly pick up PE with a high probability scan in four out of five cases with proven PE. Those patients with intermediate (indeterminate) probability VQ scan should go to further investigation with CTPA.

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Course Book EMSS04

Acute Metabolic Complications Of Diabetes by Prof. D-r. Tatjana Milenkovic Medical Faculty - Skopje

he acute metabolic complications of diabetes consist of diabetic ketoacidosis (DKA), hyperosmolar non-ketotic coma (HNC), lactic acidosis (LA), and hypoglycemia. DKA and HNC are related to insulin deficiency. Hypoglycemia results from the treatment of diabetes, either with oral agents or insulin. Although hypoglycemia may occur in conjunction with oral hypoglycemic therapy, it is more common in patients treated with insulin. LA is usually associated with other factors that may be related to diabetes, such as cardiovascular disease (acute myocardial infarction) associated with hypoxia and excess lactic acid production. The incidence rate for DKA varies with definition, age, and sex. The rate from population-based studies ranges from 4.6 to 8 per 1,000 diabetic persons per year. It is more common in young diabetic people and may be more common in women than men. DKA may be the initial manifestation of diabetes in 20% - 30% of cases. Incidence rates for HNC, LA, and hypoglycemia are not available from population-based studies. Hypoglycemic events varied in the Diabetes Control and Complications Trial (DCCT) between the treatment groups. These events were associated with the degree of normalization of glycemia. Precipitating factors for DKA, HNC, and LA include acute illness or co-morbidity such as cardiovascular disease, injury or infection, medications, and poor compliance or errors in compliance with treatment. Precipitating factors for hypoglycemia include dosage of oral hypoglycemic agent or insulin; errors in dosage administered; timing of the medication, particularly insulin; delay in meals; and co-morbidity such as renal insufficiency, adrenal insufficiency, and pituitary insufficiency. Prevention of these acute complications remains an important element in their management. Recognition of precipitating factors and appropriate instruction, awareness, and self-care will decrease the occurrence of these complications. DKA, HNC, and LA require hospitalization for treatment and thereby result in the use of significant health care resources with increased health care costs. Prevention is an important component in reducing health care cost for these disorders. Hypoglycemia can usually be treated in an ambulatory care setting without using significant health care resources. Severe hypo-

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EMSA Macedonia glycemia with loss of consciousness may necessitate hospitalization, however. Significant morbidity and mortality is associated with DKA, HNC, and LA. Prompt recognition and management of these disorders and their associated morbidity results in improvement. Mortality rates are ~9%-14% for DKA and 10%-50% for HNC. The mortality rate for LA is >50% with serum concentrations of lactic acid >5 mmol/L when associated with circulatory failure or septic shock. Hypoglycemia is usually associated with symptoms that are reversible with prompt treatment. Severe and profound hypoglycemia may be associated with long-term neurologic impairment. DKA is a disorder of glucose metabolism which is characterized by hyperglycemia, increased serum ketones (and other products by of fatty acid metabolism), metabolic acidosis and dehydration. The basic metabolic problem is a lack of insulin or in some cases, lack of cellular capacity to utilize insulin. The result is the inability to transfer glucose through the cell membrane. This results in an increasing amount of glucose in the serum, i.e., it cannot “get into” the cell. The excess glucose is excreted by the kidneys, which must lose water to keep the glucose in solution. This leads to the dehydration and increased osmolarity of the serum (an increase in dissolved products), which is a major factor in the altered mental status associated with DKA. Also, as water is drawn out through the kidneys, it carries with it sodium, potassium and other ions, contributing to the electrolyte abnormalities of DKA. A confounding factor is with profound dehydration and acidosis significant potassium loss can be “masked” in some instances. The serum level could be high but total body potassium, which is not measurable, is low. Of interest is the fact when serum ketone levels are measured in most labs, only acetoacetate and not beta-hydroxy butyrate is identified. For this reason, serum ketones, although present, are not always reported as positive in DKA. The dehydration which evolves with DKA also leads to impaired renal function, further compounding the acidosis. These metabolic changes in the absence of insulin help explain the symptoms and signs typical of diabetes, polyuria (urinating a lot), polydypsia (drinking a lot, i.e., excessive thirst), and weight loss. In spite of good food intake by the patient, weight loss occurs secondary to cellular starvation. All of the factors discussed above combine and affect one another in a manner which exacerbates the problem.

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Course Book EMSS04

Торакални и Белодробни РТГ Дијагностички Можности by Prim. D-r Blagoja Daskalov Remedika - Skopje

д самиот свој почеток,19 Век, па се до денешен ден, РТГ дијагностичките методи, представуваат неодминлив дел во откривањето, дијагностиката и спроведување на терапија, медикаментозна или хирушка, во заболувањата на белите дробови и тораксот.

1. РТГ - Флуороскопија (го прикажува движењето на дијфрагмата, но е лимитирана за детекција на патолошки промени) - Конвенционален РТГ во два правца- PA и LL - Дигитален РТГ, работни единици - Контрасни конвенционални методи 2. Ултра Звук Дава корисна слика за стуктурите околу белите дробови - плеврална ефузија, движење на дијафрагмата, дијафрагмално задебелување. Белите дробови не може да се иследуваат со УЗ поради нивната непенетрабилност за УЗ. Ограничени, ориентациони можности. (воздух најголем непријател на УЗ) Иследување на васкуларни структури - Допплер Анализа на течна содржина 3. МДКТ Пулмонум Најсовремена дијагностичка постапка, со можност за целосна 2Д и 3Д анализа, со Виртуелни реконструктивни можности. Контрасни методи Целосна анализа на бронхо - алвеоларни структури, морфолошки структурни и функционални анализи. Целосна функционална и морфолошка анализа на васкуларни структури. МДКТ ангиографска анализа.

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EMSA Macedonia 4. МРИ Отежнувачки елементи Припрема на пациент, клаустрофобии, метални тела, артефакти од движење, дензитетот на белите добови е многу пониска во споредба со дригите ткив, односно низок протон спин дензитет што резултира со многу малку МРИ сигнали. Друг отежнувачки момент е срцевата акција и респирациите што ги прави пациентот, тоа дава движечки артефакти. Новите технологии и софтверски програми (ultra fast proton gradient eho MRI) прават напори да се справат со овие лимитирани можности, но сепак главен интерес претставуваат васкуларните структури односно пулмоналната циркулација. 5. Торакални и белодробни пункциони анализи - брохоскопија, брохоскописки аналзи - Тенкоиглена аспирациона биопсија - Пункциони трансторакални “core ”биопсии Водени под конвенционален РТГ и компјутерски водени биопсии

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Современи Аспекти на Торакалната Хирургија by Prof. D-r Andreja Arsovski Remedika Skopje

оракалната хирургија е област на хирургијата која повеќе се развива во втората половина на дваесеттиот век, а денес доживува брз развој и големи успеси во третманот на торакалните заболувања. Многу важен фактор во торакалната анестезија која има свои бројни специфики со оглед на виталноста на органите во градниот кош и нивната осетливост за враме на операцијата, како и во постоперативниот период. Користењето на дволуминалните блокер тубуси денес е основна премиса за практикување на добра и безбедна белодробна хирургија. За жал, најчести индикации за белодробни ресекции претставуваат бронхијалните карциноми. Кај нив е потребно да се прават анатомски ресекции, при што радикалната лобектомија претставува операција на избор. Сепак, понекогаш мора да се направи радикална пнеумонектомија. Сегментектомијата ретко се индицира, заради недоволниот радикалитет. Кај овие операции нужно составен дел е лимфаденектомија според одредени протоколи зависно од локализацијата на карциномот и оди според мапата на Mountain - Deressler заради прецизно одредување на стадиумот на болеста. Големите крвни садови и бронхите се подврзуваат со степлер, со што се скратува времето на операции и се намалуваат компликациите. Еден од современите стандарди во торакалната хирургија денес претставува торакоскопијата (ВАТС – видеоасистирачка торакоскопска хирургија, MIS – minimal invasive surgery ). Тоа е ендоскопска или минимално инвазивна хирургија со која што се овозможува минимална агресија на организмот со хируршката постапка. Голема е палетата на оперативни процедури кои можат да се изведуваат со помош на БАТС. Сепак се уште постојат pro et contra ставови за изведување на радикални онколошки операции со ВАТС. Исто така дискутабилни се и бенефитите од користење на роботска хирургија со Da Vinci робот во торакалната хирургија. Од новите технологии нешто што е голем бенефит, тоа е користењето на ласерската хирургија, особено во третманот на метастазите во белите дробови. Многу е интересен развојот на ткн. Lung Volume Reduction Surgery која се користи кај пациентите со тежок белодробен емфизем. Парадоксот е што со делумно отстранување на нефункционалниот и крајно оштетен белодробен паренхим, се овозможува на условно речено, поздравиот дел да функционира подобро

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EMSA Macedonia и иако се намалува вкупниот паренхим, дишната функција и белодробните капацитети се подобруваат. Во овој контекст треба да напоменеме дека современиот концепт на третманот на пнеумотораксот денес е важно променет во однос на минатите децении, така да кај пнеумотораксот рутински и редовно се прави торакоскопија за подобра дијагностика и правилен третман на истиот. На крај да ја споменеме и трансплантацијата на белите дробови, која е можеби и најтешката трансплантација со оглед на спецификите на анатомијата и физиологијата на белите дробиви. Во минатата декада резултатите од белодробните трансплантации во однос на петгодишното преживување, како и во однос на квалитетот на животот се драстично променети. Исто така и индикациите за белодробтаната трансплантација се сега многу подобро дефинирани.

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Course Book EMSS04

CPR: European Guidelines For Life Support 2010 by Prof. D-r Mirjana Shosholcheva University Clinic of Surgery “St. Naum Ohridski” - Skopje

n this classroom-based course, students will learn to recognize several life-threatening emergencies, provide CPR to victims of all ages and use an AED, in a safe, timely and effective manner. Guidelines for cardiopulmonary resuscitation (CPR) from the European Resuscitation Council (ERC) are updated every two years. These 2010 guidelines are based on the most recent International Consensus on CPR Science. This executive summary provides the essential treatment algorithms for the resuscitation of adults and highlights the main guideline changes since 2005. Performing CPR is very much connected with The Chain of Survival. The actions linking the victim of sudden cardiac arrest with survival are called the Chain of Survival (Fig.1). The first link of this chain indicates the importance of recognizing those at risk of cardiac arrest and calling for help in the hope that early treatment can prevent arrest. The central links represent the integration of CPR and defibrillation as the fundamental components of early resuscitation in an attempt to restore life. For example, immediate CPR can double or triple survival from VF. The final link in the Chain of Survival, effective post-resuscitation care, is targeted at preserving function, particularly of the brain and heart. In the hospital, the importance of early recognition of the critically ill patient and activation of a medical emergency or rapid response team, with treatment aimed at preventing cardiac arrest, is now well accepted. Over the last few years, the importance of the postcardiac arrest phase of treatment, represented in the fourth ring of the Chain of Survival, has been increasingly recognized. The algorithm of BLS includes several steps. At the beginning we have to be sure that the victim and any bystanders are safe. After that checking the victim for a response, gently shaking his shoulders and asking loudly “Are you all right?” is the second step. If the victim responds it is recommended to leave him in the position in which he is found, provided that there is no further danger. Trying to find out what is wrong with him and get help if needed is the next step, reassess him regularly. If he does not respond, than shouting for help and turning the victim onto his back and then open the airway using head tilt and

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HOW TO SAVE A LIFE... chin lift is another step. Recognition of cardiorespiratory arrest All rescuers should be trained to focus on the recognition of unresponsiveness and the quality of breathing. In combination with unresponsiveness, absence of breathing or any abnormality of breathing should start a dispatch protocol for suspected cardiac arrest. The importance of gasping as sign of cardiac arrest is emphasized. Protocols must be followed as it appears at the diagram above. Checking for carotid pulse (or any other pulse) is an inaccurate method for confirming the presence or absence of circulation. Checking pulse on a.carotis must be in a time of 10 sec in order to save time for successful resuscitation. Healthcare professionals, as well as lay rescuers, have difficulty determining the presence or absence of adequate or normal breathing in unresponsive victims. This may be because the victim is making occasional (agonal) gasps, which occur in the first minutes after onset in up to 40% of cardiac arrests. Lay rescuers should be taught to begin CPR if the victim is unconscious (unresponsive) and not breathing normally. It should be emphasized during training that the presence of agonal gasps is an indication for starting CPR immediately. Keeping the airway open Mandatory is to look, listen and feel for breathing: •

to look for chest movement;

•

to listen at the victim’s mouth for breath sounds;

•

to feel the air on your cheek;

•

to decide if the breathing is normal, not normal or absent.

Looking listening and feeling is an action that is also important to be no more than 10s to determine whether the victim is breathing normally. If any doubt exists whether breathing is normal, acting as if it is not is obligatory. If the victim is breathing normally, then turning him into the recovery position and calling for help with continuing to asses that breathing remains normal. EMSA Macedonia Summer School 2013

Course Book EMSS04 Recovery position There are several variations of the recovery position, each with its own advantages. No single position is perfect for all victims. The position should be stable, neat to a true lateral position with the head dependent, and with no pressure on the chest to impair breathing. Foreign-body airway obstruction (choking) Foreign-body airway obstruction is an uncommon but potentially treatable cause of accidental death. The adult foreign body airway obstruction (choking) sequence is shown in Fig.3.

If the breathing is not normal or absent, than it is recommended to start with: Initial rescue breaths In adults needing CPR, the cardiac arrest is likely to have a primary cardiac cause â&#x20AC;&#x201C; CPR should start with a chest compression rather than initial ventilations. Time should not be spent checking the mouth for foreign bodies unless attempted rescue breathing fails to make the chest rise. Rescuers should give each rescue breath over about 1s, with enough volume to make the victimâ&#x20AC;&#x2122;s chest rise, but to avoid rapid or forceful breaths. The time taken to give two breaths should not exceed 5s. These recommendations apply to all forms of ventilation during CPR, including mouth-to-mouth and bag-mask ventilation with and without supplementary oxygen. Chest compression The importance of early, uninterrupted chest compressions is emphasized throughout these 2010 guidelines. All rescuers trained or not, should provide chest compressions to victims of cardiac arrest. A strong emphasis on delivering high quality chest compression remains essential. Chest compression generate a small but crucial amount of blood flow to the brain and myocardium and increase the likelihood that defibrillation will be successful. Optimal chest compression technique comprises: compressing the chest at a rate of at least 100 min and to a depth of at least 5cm (for an adult), but not exceeding 6cm; allowing the chest to recoil completely after each compression; taking approximately the same

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EMSA Macedonia amount of time for compression as relaxation. Rescuers can be assisted to achieve the recommended compression rate and depth by prompt/feedback devices that are either built into the AED or manual defibrillator, or are stand-alone devices. Trained rescuers should also provide ventilation with a compression-ventilation (CV) ration of 30:2. The two breaths should not take more than 5s in all. Continue with chest compression and rescue breaths in a ratio of 30:2. Stopping is allowed to recheck the victim only if he stars to wake up: to move, open eyes and to breathe normally. Otherwise it is not recommended to interrupt resuscitation. If the initial rescue breath does not make the chest rise as in normal breathing, then before the next attempt it is recommended to look into the victimâ&#x20AC;&#x2122;s mouth and remove any obstructions; to recheck that there is adequate head tilt and chin lift; and to make attempt no more than two breaths each time before returning to chest compressions. The recommendation is not to interrupt resuscitation until professional help arrives and takes over; or the victim starts to wake up: to move, opens eyes and to breathe normally; or if rescuer becomes exhausted. If there is more than one rescuer present, another rescuer should take over delivering CPR every 2min to prevent fatigue. It is very important to ensure that an interruption of chest compressions is minimal during the changeover of rescuers. Compression-only CPR Some healthcare professionals as well as lay rescuers indicate that they would be reluctant to perform mouth-to-mouth ventilation, especially in unknown victims of cardiac arrest. Animal studies have shown that chest-compression-only CPR may be as effective as combined ventilation and compression in the first few minutes after non-asphyxial arrest. If the airway is open, occasional gasps and passive chest recoil may provide some air exchange, but this may result in ventilation of the dead space only. Chest-compressiononly may be sufficient only in the first few minutes after collapse. Chest-compressiononly CPR is not as effective as conventional CPR for cardiac arrest of non-cardiac origin (e.g. drowning or suffocation) in adults and children. Chest compression combined with rescue breaths is, therefore, the method of choice for CPR delivered by both trained lay rescuers and professionals. Chest-compression-only CPR may be used if the rescuer is not trained, or is unwilling to give rescue breaths. In that case recommendation is to give chest compressions only, to continue giving at a rate of at least 100min (but not exceeding 120min) until help arrives. To summarize: the most important changes in the 2010 ERC Advanced Life Support (ALS) Guidelines include increased emphasis on the importance of minimally interrupted high-quality chest compressions throughout any ALS intervention: chest compressions are paused briefly only to enable specific interventions.

EMSA Macedonia Summer School 2013

Course Book EMSS04

Emergencies in Gastroenterology:

Acute Gastrointestinal Bleeding by D-r Vladimir Avramoski Department of Gastroenterology and Hepatology University Clinical Centar - Skopje

espite advances in modern medicine and lifestyle of the world population, gastrointestinal (GI) bleedings remains serious problem and challenge for physicians all over the world. According to the intensity and the amount of blood loss, GI bleedings are divided into acute and chronic, both with different clinical presentation and type of anemia. The aim of this text is a closer look up to the acute GI bleedings as an urgent medical issue in the Gastroenterology. Acute GI bleedings are manifested with appearance of hemathemesis (vomiting of bright red colored or coffe ground like colored blood), melena (black colored stool) and hematochezia (passage of bright red colored blood from the rectum). Due to practical reasons and the location of the bleeding site, acute GI bleedings are divided into two major groups: upper and lower GI bleedings (upper GI bleedings origins from the bleeding site located above the insertion of the lig. Treitz and lower GI bleedings deriving from a bleeding site located beneath the lig. Treitz). Depending on the amount of the blood loss, the symptoms range from appearance of trivial hemorrhage to manifestation of orthostatic hypotension and hemodynamic shock. Acute upper GI bleedings is gastroenterological emergency with a mortality of 6-13% [1]. Despite changes in management, mortality has not significantly improved over a period of 50 year [2]. Bleeding from the upper gastrointestinal tract (GIT) is four to five times as common as bleeding from the lower GIT. The most common causes of acute upper GI bleeding are: peptic ulcer, esophagitis, gastritis, erosive duodenitis, varices, portal hypertensive gastropathy, malignancy, Mallory-Weiss tear, vascular malformation. Rare causes include Diealafoyâ&#x20AC;&#x2122;s lesion, angiodysplasia, hemobilia, pancreatic pseudocyst and pseudoaneurism, aortoenteric fistula, bleeding diathesis, Ehlers-Danlos syndrome, pseudoxanthoma elasticum, gastric antral vascular ectasia, Osler-Weber-Rendu syndrome[3]. Annually, approximately 100.000 patients are admitted to US hospitals for therapy of acute upper GI bleeding [4]. European studies offer variety of results: in France the mortality from acute upper GI bleeding has decreased from 11% to 7%, but on the other hand in Greece there is no decrease in mortality. According to the nationwide study from Spain, acute upper GI bleeding was 6 times more common than lower GI bleeding [5]. The incidence of upper GI bleeding is 2-fold greater in males than in females, in all age groups; however, the death rate is similar in both sexes [6]. The population with acute upper GI bleeding has become progressively older, with a concurrent increase in significant comor-

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EMSA Macedonia bidities that increase mortality. Mortality increases with older age (> 60 years) in males and females [7]. Recommendations emphasize early risk stratification, using validated prognostic scales and early (within 24 hours). The following formal risk assessment scores are recommended by the National Institute for Health and Clinical Excellence (NICE) for all patients with acute upper GI bleeding: [2] The Blatchford score at first assessment and the full Rockall score after endoscopy. The Blatchford risk assessment is designed to be used pre-endoscopy. Scores are added using the level of urea, hemoglobin, systolic blood pressure, pulse rate, presentation with melena, presentation with syncope, hepatic disease and cardiac failure. A score of 0 is the cut-off with any patient scoring >0 being at risk of requiring an intervention. The Scottish Intercollegiate Guidelines Network (SIGN) guideline on the management of the acute upper and lower GI bleeding recommends that an initial (pre-endoscopic) Rockal score should be calculated for all patients presenting with acute upper GI bleeding. In patients with an initial Rockal score >0 endoscopy is recommended for a full assessment of bleeding risk. [3] Acute lower GI bleeding is a frequent cause of hospital admission and is a factor in hospital morbidity and mortality. Acute lower GI bleeding it is distinct from upper GI bleeding in epidemiology, management and prognosis. The most common causes of acute lower GI bleeding are diverticular bleeding, malignancy, angiodysplasia, ischemic colitis, radiationinduced colitis and inflammatory causes. Acute lower GI bleeding that require hospitalization represents less than 1% of all hospital addmisions in US. In one study, the estimated annual incidence rate was 20.5 patients per 100.000 (24.2 in males vs 17.2 in females) [8]. Acute lower GI bleeding somewhat more common in men than in women, because diverticulosis and vascular disease are more common in men. Diverticulosis accounts for around 30-50% of the cases of hemodynamically significant lower GI bleeding, whereas angiodysplasia accounts for about 20-30% of cases. Lower acute GI bleeding is more commen in elderly than in younger people because diverticulosis and vascular disease are more common in this groups. Some experts believe that angiodysplasia is the most frequent cause of lower GI bleeding in patients older than 65 years. In diagnoses of GI bleedings primary tool is always endoscopy (upper and lower endoscopy), whereas in identifying obscure acute bleedings there are other diagnostic methods like classic angiography, CT angiography and nuclear imaging as secondary tools. In very small portion there is a need for surgical diagnostic intervention. Treatment for both upper and lower GI bleedings primarily consists of localization of the bleeding site, correction of fluid loses and therapeutic intervention to stop bleeding at the site. In correction of fluid losses we use normal saline, plasma expanders, red cell transfusion if blood loss is more than 30% of the total circulatory volume, transfusion of fresh frozen plasma, prothrombin complex concentrate for patients taking Warfarine and actively bleeding, and finaly recombinant factor VIIa which should be used only when all other methods have failed. Proton pump inhibitors should not be used prior to diagnosis by endoscopy in patients presenting with acute upper GI bleeding. Therapeutic interventions used to stop the bleeding at site are: endoscopic treatment with injections of vasoconstrictors or slcerosing agents, placement of hemoclips, band ligation and thermal coagulation of the blood wessel. Very rare there is a need to use superselective embolization EMSA Macedonia Summer School 2013

Course Book EMSS04 with agents such as gelatin sponge, coil springs, polyvinyl alcohol and oxidized cellulose. Emergency surgery is required in 3-5% of upper GI bleedings and 10-25% with lower GI bleedings. The indications for surgery include the following: persistant hemodynamic instability with active bleeding, persistent recurrent bleeding, transfusion of more than 4 units packed red blood cells in a 24 h period with active or recurrent bleeding.

1. Holster IL, Kuipers EJ; Management of acute non-variceal upper gastrointestinal bleeding: current policies, World J Gastroenterol. 2012 Mar 21:18 (11): 1202/ 2.

Acute GI bleeding, NICE Clinical Guideline (June 2012)

3. Management of upper and lower gastrointestinal bleeding, Scottish Intercollegiate Guidelines Neetwork â&#x20AC;&#x201C; SIGN (Sept 2008) 4.

Emedicine. Medscape.com/article/187857-overview#a0156

5. Lanas A, Perez-Aisa MA, Feu F, Ponce J, Saperas E, Santolaria S, et al. A nationwide study of mortality associated with hospital admission due to severe gastrointestinal events and those associated with nonsteroidal antiinflamatory drug use, Am J Gastroenterol. Aug 2005; 100(8):1685-93 [Medline] 6. Yavorski RT, Wong RK, Maydonotovitch C, Battin LS, Furnia A, Amundson DE, Analysis of 3.924 cases of upper gastrointestinal bleeding in military medical facilities, AM J Gastroenterl. Apr 1995;90(4):56873. [Medline] 7. Pilloto A, Maggi S, Noale M, Franceschi M, Parisi G, Crepaldi G, Development ande validation of a new questionnaire for the evaluation of upper gastrointestinal symptoms in the elderly population: a multicenter study. J Gerontol A Biol Sci Med Sci, Feb 2010;65(2):174-8 [Medline] 8. Longstreth GF, Epidemiology and outcome of patients hospitalized with acute lower gastrointestinal hemorrhage: A population â&#x20AC;&#x201C; based study, Am J Gastroenterol. Mar 1997; 92 (3):419-24 [Medline]

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EMSA Macedonia

Lumbar Puncture:

Indication, Contraindication and CF Syndromes by Prof. D-r Natalija Dolnenec Baneva University Clinical Centar - Skopje Indications ● Bacterial meningitis ● If the patient has neurologic deficit symptoms or impaired consciousness, neurological imaging should be performed before lumbar puncture. If necessary, antibiotic treatment can commence after a blood culture sample has been obtained. A delay in the performance of CSF examination must not cause delay in the commencement of antibiotic treatment. ● Viral meningitis ● Neuroborreliosis ● Other infectious or inflammatory CNS diseases ● CT is the primary diagnostic procedure for SAH. Lumbar puncture is indicated if the CT is negative and there is a clinical probability of SAH (5% of cases). A normal finding on CT does not rule out SAH. ● Lumbar puncture may be performed in order to rule out SAH in a situation where a CT scan is not available and the patient’s condition is good, or when SAH has taken place 1 to 14 days earlier (examine siderophages and erythrophages, take a cytologic sample or examine the CSF spectrum). Contraindication ● Focal neurological signs when imaging examination has not been performed ● Suspected increased intracranial pressure (risk of cerebellar herniation!): ● Papilloedema ● Symptoms such as morning headache, vomiting, impaired consciousness ● In unclear situations, such as lack of patient cooperation that prevents the examination of eye fundi, CT of the head is indicated before lumbar puncture. Relative contraindication ● Anticoagulant therapy or other bleeding tendency. Considerations related to on duty lumbar puncture ● If meningitis is suspected, culture the sample in a special dish (procure the necessary EMSA Macedonia Summer School 2013

Course Book EMSS04 dish in advance) or, in a case of emergency, in a blood culture bottle, and keep part of the sample for bacterial staining. ● Take an extra tube of CSF to be stored in the laboratory refrigerator for possible further tests. ● Time of the lumbar puncture and its performance need to be documented in the medical records as also any problems and artefact blood, as the latter may lead to a false suspicion of SAH and consequent unnecessary examinations. ● If the patient is sent home soon after the lumbar puncture, he/she must be told to anticipate possible post-puncture headache and how to treat it. Suggestions for technical performance of lumbar puncture ● The puncture is normally made between L3–L4 or L4–L5, either above or below the level of the iliac crest. ● Check the patient’s position yourself. ● The most common error is to have the spine twisted instead of only being bent forward. ● Palpate carefully, make clear for yourself the spatial configuration of the patient’s spine, and make sure where to puncture. ● Local anaesthesia removes the sensation of pain in the skin surface and may calm down the patient. The needle used for local anaesthesia is often as thick as the puncture needle and does not remove the sensation of pain in the deeper tissues. It is forbidden to anaesthetize the deeper tissue layers as the anaesthetic may enter the spinal cavity. ● If there is scar formation from a previous back operation, the tissue will be harder than normal, and a thicker needle should be used to avoid bending. ● The puncture may be technically impossible to perform if the patient is very obese, has a history of lumbar bone graftings or has severe spinal stenosis. Herniation of the cerebellum after lumbar puncture ● Extremely rare. ● Immediately or a few hours after the puncture the patient loses consciousness, his/her respiration becomes irregular and ceases. ● Maintain vital functions, usually respiration; the heart will function. ● Adjust the bed into the steep Trendelenburg’s position (supine position with pelvis higher than the head). ● Administer mannitol intravenously. ● Consult a neurosurgeon. Postpunctional headache ● Probably caused by loss of CSF pressure in the head. ● The onset of headache is more related to the amount of fluid leaking extradurally after

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EMSA Macedonia the puncture than the amount of fluid withdrawn as a sample. Bedrest after puncture does not prevent headache. ● Patients with a history of headache and possibly patients with MS are more susceptible to prolonged (1–2 weeks) postpunctional headaches. HSF analysis ● Normally colourless, clear ● Turbid, opaque → bacterial meningitis ● Evenly bloody, liquid (“lingonberry juice”), reddish/yellow-red after centrifugation (xanthochromia) → haemorrhage ● Yellow → old haemorrhage, very high protein concentration. An old haemorrhage may be associated with mild leucocytosis of the CSF (10–50/mm3). Occasionally this kind of spinal fluid is coagulated. It can be examined by heating to 37°C. ● The fluid is coagulated, streaked with blood; bloody, but later clear, colourless after centrifugation → artefact blood.

EMSA Macedonia Summer School 2013

Course Book EMSS04

How to Guide

Monitoring Blood Glucose by Prof. D-r Katarina Stavrikj Institute for Family Health

he early detection of diabetes, especially in risk groups, and the good treatment of diabetes and maintenance of blood glucose at the desired levels strongly reduce cardiovascular complications and target damage. A glucometer is a medical device for determining the concentration of the glucose in the blood. It is a key element of home blood glucose monitoring by people with diabetes mellitus. Measuring glucose in primary care: First, set out your glucometer, a test strip, a lancet and an alcohol prep pad. 1. Wash your hands to prevent infection. 2. Decide where you are going to obtain the blood from, usually a finger. Some of the newer monitors let you use your forearm or another less sensitive place. 3. Sometimes it helps to warm your hands first to make the blood flow easier. You can rub your hands together briskly or run them under warm water. 4. Turn on the glucometer and place a test strip in the machine when the machine is ready. Watch the indicator for placing the blood to the strip. 5. Make sure your hand is dry and wipe the area youâ&#x20AC;&#x2122;ve selected with an alcohol prep pad and wait until the alcohol evaporates. 6. Pierce your finger tip on the soft, fleshy pad and obtain a drop of blood. The type of drop of blood is determined by the type of strip you are using

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EMSA Macedonia (some use a “hanging drop” of blood versus a small drop for strips that draw blood in with a capillary action). 7. Place the drop of blood on or at the side of the strip. 8. The glucometer will take a few moments to calculate the blood sugar reading. Follow your doctor’s orders for whatever blood sugar reading you get. 9. You may use the alcohol prep pad to blot the site where you drew the blood if it is still bleeding. 10. Write down your results. Keeping a record makes it easier for you and your doctor to establish a good treatment plan. Some glucometers can store your results in a memory, for easier record keeping. Interpretation of the results: Fasting blood glucose (after 8-14 hours of fasting) • Normal blood glucose level should be < 6.1 mmol / L. • The results as obtained from 6.1 to 7.0 mmol / L. require evaluation and monitoring. Postprandial glucose and / or HbA1c, and / or OGTT should be done. In those patients it is necessarily to begin with preventive measures. • Value of blood glucose > 7.0 mmol / L received in 2 separate times is diabetes. Postprandial blood glucose • Postprandial blood glucose (1.5 to 2 hours after a meal) values from 7.8 to 11.1 mmol/L represent the state of prediabetes and it is necessary to do evaluation and monitoring. • Values of blood glucose > 11.1 mmol / L. represent diabetes. HbA1C (A1C or glycosylated hemoglobin test) The A1C can be used for the diagnosis of both prediabetes and diabetes. The A1C test measures your average blood glucose control for the past 2 to 3 months. This test is more convenient because no fasting is required. • An A1C of 5.7% to 6.4% means that you are at high risk for the development of diabetes and you have prediabetetes. • Diabetes is diagnosed when the A1C is 6.5% or higher.

EMSA Macedonia Summer School 2013

Course Book EMSS04

How to Guide

Auscultation Of The Heart And Lungs by Prof. D-r Katarina Stavrikj Centre for Family Medicine

amiliarity with normal and abnormal heart sounds provides the foundation for many clinical assessments. Cardiac auscultation provides information about the rate and rhythm of the heart, valve function, and possible anatomical defects. It requires a methodical approach with careful attention to the sounds produced during the cardiac cycle. Nurses providing direct patient care need to have a clear understanding of auscultation techniques, practices, and skills - skills which can diminish if not routinely employed. This three-part series on cardiac auscultation provides a review of the anatomy and physiology of the heart and the sounds it produces as it works, demonstrates and describes the proper equipment and techniques used in cardiac auscultation, and provides descriptions and examples of normal heart sounds. These visual aids have been developed specifically to enhance instruction and study of anterior and posterior heart and lung auscultation site locations. The front sides of the double-sided sheets illustrate the six anterior heart site locations, describe 12 heart conditions, and explain what would be expected to be heard at each site based off of the condition type. The backs of the sheets illustrate anterior and posterior lung site locations, describe 16 lung conditions, and explain what would be expected to be heard at each site based off of the condition type. These teaching aids will enhance auscultation education.

Heart Sounds Normal heart sounds are associated with heart valves closing, causing changes in blood flow. First heart sounds S1 The first heart tone, or S1, forms the “lub” of “lub-dub” and is composed of components M1 and T1. Normally M1 precedes T1 slightly. It is caused by the sudden block of reverse blood flow due to closure of the atrioventricular valves, i.e. tricuspid and mitral (bicuspid), at the beginning of ventricular contraction, or systole. When the ventricles begin to contract, so do the papillary muscles in each ventricle. The papillary muscles are attached to the tricuspid and mitral valves via chordae tendineae, which bring the cusps or leaflets of the valve closed. The closing of the inlet valves prevents regurgitation of blood from the ventricles back into the atria. On occasion the first heart sound can be made up of two separate sounds separated by

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EMSA Macedonia a very small interval (20-30 milliseconds). The Mitral component (caused by closure of the Mitral valve) comes first and is louder than the Tricuspid component (caused by closure of the Tricuspid valve). A minimally split first heart sound is a normal variation of the first heart sound. Second heart sound S2 The second heart tone, or S2, forms the “dub” of “lub-dub” and is composed of components A2 and P2. Normally A2 precedes P2 especially during inspiration when a split of S2 can be heard. It is caused by the closure of the semilunar valves (theaortic valve and pulmonary valve) at the end of ventricular systole, i.e. beginning of ventricular diastole. As the left ventricle empties, its pressure falls below the pressure in the aorta. Aortic blood flow quickly reverses back toward the left ventricle, catching the pocket-like cusps of the aortic valve, and is stopped by aortic (outlet) valve closure. Similarly, as the pressure in the right ventricle falls below the pressure in the pulmonary artery, the pulmonary (outlet) valve closes. Splitting of S2, also known as physiological split, normally occurs during inspiration because the decrease in intrathoracic pressure increases the time needed for pulmonary pressure to exceed that of the right ventricular pressure. A widely split S2 can be associated with several different cardiovascular conditions, including right bundle branch block, pulmonary stenosis and atrial septal defect. The rarer extra heart sounds form gallop rhythms and are heard in both normal and abnormal situations.

Extra Heart Sounds Third heart sound S3 Rarely, there may be a third heart sound also called a protodiastolic gallop, ventricular gallop, or informally the “Kentucky” gallop as an onomatopoeic reference to the rhythm “lub-dub-ta” It occurs at the beginning of diastole after S2 and is lower in pitch than S1 or S2 as it is not of valvular origin. The third heart sound is benign in youth, some trained athletes, and sometimes in pregnancy but if it re-emerges later in life it may signal cardiac problems like a failing left ventricle as in dilated congestive heart failure (CHF). S3 is thought to be caused by the oscillation of blood back and forth between the walls of the ventricles initiated by blood rushing in from the atria. The reason the third heart sound does not occur until the middle third of diastole is probably that during the early part of diastole, the ventricles are not filled sufficiently to create enough tension for reverberation. It may also be a result of tensing of the chordae tendineae during rapid filling and expansion of the ventricle. In other words, an S3 heart sound indicates increased volume of blood within the ventricle. An S3 heart sound is best heard with the bell-side of the stethoscope (used for lower frequency sounds). A left-sided S3 is best heard in the left lateral decubitus position and at the apex of the heart, which is normally located in the 5th left intercostal space at the midclavicular line. A right-sided S3 is best heard at the EMSA Macedonia Summer School 2013

Course Book EMSS04 lower-left sternal border. The way to distinguish between a left and right-sided S3 is to observe whether it increases in intensity with inspiration or expiration. A right-sided S3 will increase on inspiration whereas a left-sided S3 will increase on expiration.An S3 corresponds to rapid ventricular filling during early diastole. It is caused by vibration of the ventricular wall when blood from the atrium hits the ventricular wall. It is heard just after S2 (just after the mitral valve opens and the aortic valve shuts). The third heart sound is low in frequency and intensity (hear better with the bell at the apex in the left lateral decubitus position). It may occur in normal children and young adults, especially if stroke volume is increased. After about 40 years of age an S3 should be considered abnormal; It is caused by conditions that increase the volume of ventricular filling during early diastole (e.g., mitral regurgitation), by filling into a ventricle with decreased compliance, or from filling into. Fourth sound S4

S4 when audible in an adult is called a presystolic gallop or atrial gallop. This gallop is produced by the sound of blood being forced into a stiff/hypertrophic ventricle - “talub-dub” or “a-stiff-wall”. It is a sign of a pathologic state, usually a failing left ventricle, but can also be heard in other conditions such as restrictive cardiomyopathy. The sound occurs just after atrial contraction (“atrial kick”) at the end of diastole and immediately before S1, producing a rhythm sometimes referred to as the “Tennessee” gallop where S4 represents the “Ten-” syllable. It is best heard at the cardiac apex with the patient in the left lateral decubitus position and holding his breath. The combined presence of S3 and S4 is a quadruple gallop, also known as the “Hello-Goodbye” gallop. At rapid heart rates, S3 and S4 may merge to produce a summation gallop. Under pathologic conditions, forceful atrial contraction (“atrial kick”) late in diastole can generate a low-frequency sound (S4) just before S1 . An S4 is common in adults older than 40 or 50 years because of reduced ventricular compliance (increase resistance to ventricular filling) during atrial contraction; a forceful atrial contraction into a hypertrophied, noncompliant ventricle almost always produces an early and easily audible S4. The severe LV hypertrophy present in systemic hypertension, severe valvular aortic stenosis, and hypertrophic cardiomyopathy is often responsible for a loud S4. Atrial contraction must be present for production of an S4. Heart murmurs are produced as a result of turbulent flow of blood, turbulence sufficient to produce audible noise. They are usually heard as a whooshing sound. The term murmur only refers to a sound believed to originate within blood flow through or near the heart; rapid blood velocity is necessary to produce a murmur. It should be noted that most heart problems do not produce any murmur and most valve problems also do not produce an audible murmur. ● Regurgitation through the mitral valve is by far the most commonly heard murmur, producing a pansystolic/holosystolic murmur which is sometimes fairly loud to a practiced ear, even though the volume of regurgitant blood flow may be quite small.

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EMSA Macedonia ● Stenosis of the aortic valve is typically the next most common heart murmur, a systolic ejection murmur. This is more common in older adults or in those individuals having a two, not a three leaflet aortic valve. Gradations of Murmurs (Defined based on use of an acoustic, not a high-fidelity amplified electronic stethoscope) ● Regurgitation through the aortic valve, if marked, is sometimes audible to a practiced ear with a high quality, especially electronically amplified, stethoscope. Generally, this is a very rarely heard murmur, even though aortic valve regurgitation is not so rare. ● Stenosis of the mitral valve, if severe, also rarely produces an audible, low frequency soft rumbling murmur, best recognized by a practiced ear using a high quality, especially electronically amplified, stethoscope. Other audible murmurs are associated with abnormal openings between the left ventricle and right heart or from the aortic or pulmonary arteries back into a lower pressure heart chamber. An innocent murmur is a type of murmur is seen with non-cardiac conditions such as pregnancy, hyperthyroidism, exercise and anemia. When these are treated appropriately the systolic murmur disappears. The murmur is heard in early systole, is of short duration and has a frequency range of 120 hz to 250 hz. It is best auscultated in the pulmonic area and increases in intensity with inspiration. It can be heard with either the bell or diaphragm. The short duration and mid-range frequency characterize an innocent murmur. The following paragraphs overview the murmurs most commonly heard in adults who do not have major congenital heart abnormalities. Heart Conditions-Auscultation findings:

Aortic Regurgitation-Ejection sound, loud mid systolic and soft early diastolic blowing murmur in aortic second right intercostal space, pulmonic second left intercostal space, Erbs point, fourth left intercostal space. Pulmonary stenosis- Moderate 4th sound, harsh late peaking systolic murmur, soft late pulmonic 2th sound in pulmonic second left intercostal space Mitral stenosis- Severe held expiration, tachycardia: opening snap.03 seconds after loud 2 nd sound in Erbs points third left intercostal space. Constrictive pericarditis/knock. Inspiratory augmentation indicates a gallop of right ventricular origin in fourth left intercostal space. Held expiration, tachycardia: opening snap, mid diastolic and presystolic murmurs, loud first sound on apex. Holosystolic murmur-Patient has mitral regurgitation and frequent premature ventricular contractions.murmur is crescendo-decresendo with late peaking.Soft S3 in mid diastole in apex. Midsystolic murmur –Patient with hypertrophic cardiomyopathy has a murmur that beEMSA Macedonia Summer School 2013

Course Book EMSS04 gins after S1 and ends before S2 on apex. S3 Gallop-Patient has a readily heard third heart sound. S3 occurs later in diastole that the opening snap on apex

Grade

Description

Grade 1

Very faint, heard only after listener has “tuned in”; may not be heard in all positions. Only heard if the patient “bears down” or performs the Valsalva maneuver. Quiet, but heard immediately after placing the stethoscope on the chest. Moderately loud. Loud, with palpable thrill (i.e., a tremor or vibration felt on palpation)[3] Very loud, with thrill. May be heard when stethoscope is partly off the chest. Very loud, with thrill. May be heard with stethoscope entirely off the chest.

Grade 2

Grade 3 Grade 4

Grade 5

Grade 6

S4 Gallop-Patient with left ventricular hypertrophy has a fourth sound (S4) that is not heard on every cycle. The sound is presistoliic about one second before S1 on apex. Midsystolic Click-Patient has mitral prolapse which produces a midbsystolic click heard during inspiration on apex Atrial septal defect-Respiration: mid systolic murmur,fixed split 2nd,soft 3rd, breath sounds with inspiration in pulmonic second left intercostal space. Respiration: midsystolic murmur, fixed split 2nd, middiastolic murmur in fourth left intercostal space. Patent ductus arteriosus- Continuous pulmonal murmur in second left intercostal space and fourth left intercostal space.

Ventricular septal defect – holosystolic murmur with late crescendo on Erb point and fourth left intercostal space. Lung Conditions

Vesicular normal breath sounds are soft and low pitched with a rustling quality during inspiration and are even softer during expiration. These are the most commonly auscultator breath sounds, normally heard over the most of the lung surface. They have an inspiration/expiratory ratio of 3 to 1 or I : E of 3:1. Fine crackles are brief, discontinuous, popping lung sounds that are high-pitched. Fine crackles are also similar to the sound of wood burning in a fireplace, or hook and loop fasteners being pulled apart or cellophane being crumpled. Coarse crackles are discontinuous, brief, popping lung sounds. Compared to fine crackles they are louder, lower in pitch and last longer. They have also been described as a bubbling sound. You can simulate this sound by rolling strands of hair between your

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EMSA Macedonia fingers near your ear. Wheezes are adventitious lung sounds that are continuous with a musical quality. Wheezes can be high or low pitched. High pitched wheezes may have an auscultation sound similar to squeaking. Lower pitched wheezes have a snoring or moaning quality. The proportion of the respiratory cycle occupied by the wheeze roughly corresponds to the degree of airway obstruction. Wheezes are caused by narrowing of the airways. Low pitched wheezes (rhonchi) are continuous, both inspiratory and expiratory, low pitched adventitious lung sounds that are similar to wheezes. They often have a snoring, gurgling or rattle-like quality. Rhonchi occur in the bronchi. Sounds defined as rhonchi are heard in the chest wall where bronchi occur, not over any alveoli. Rhonchi usually clear after coughing. Bronchial breath sounds are hollow, tubular sounds that are lower pitched. They can be auscultated over the trachea where they are considered normal. There is a distinct pause in the sound between inspiration and expiration. I:E ratio is 1:3 . Pleural rubs are discontinuous or continuous, creaking or grating sounds. The sound has been described as similar to walking on fresh snow or a leather-on-leather type of sound. Coughing will not alter the sound. They are produced because two inflamed surfaces are sliding by one another, such as in pleurisy. During auscultation, pleural rubs can usually be localized to a particular place on the chest wall. They also come and go. Because these sounds occur whenever the patient’s chest wall moves, they appear on inspiration and expiration. Pleural rubs stop when the patient holds her breath. If the rubbing sound continues while the patient holds a breath, it may be a pericardial friction rub. Bronchovezicular-Inspiration to expiration periods are equal with bronchovesicular lung sounds. These are normal sounds in the mid-chest area or in the posterior chest between the scapula. They reflect a mixture of the pitch of the bronchial breath sounds heard near the trachea and the alveoli with the vesicular sound. They have an I:E ratio of 1:1. Egophony E- has higher intensity over abnormal areas. Over healthy lung areas, egophony will not be present. Ask the patient to say “Eeee” several times and auscultate the chest walls. Over healthy lung areas, the sound is understandable as an “E”. Compare this sound to the recording in the “Egophony - a” lesson. Egophony A- is a voiced sound with a nasal quality, often described to be like a goat’s bleating. Egophony has higher intensity over abnormal lung areas. Ask the patient to say “Eeee” several times. Auscultate the chest walls. Over consolidated lung areas, the sound is heard as an “A” (aaay). Compare this sound to the recording in the “Egophony - e” lesson. Whispered Pectoriloquy – Healthy When a patient whispers ‘1-2-3’, the voice high frequencies, or soft vowel sounds are dampened in a normal lung. Ask the patient to whisper ‘1-2-3’ several times while ascultating the chest walls. Over EMSA Macedonia Summer School 2013

Course Book EMSS04 healthly lung areas, ‘1-2-3’ is not intelligible. Compare this sound to the recording found in the “Whispered Pectoriloquy - Abnormal” lesson. Whispered Pectoriloquy – Abnormal Voice high frequencies are more readily transmitted to the chest wall in abnormal lungs as compared to normal lungs. Ask the patient to whisper “1-2-3” several times while auscultation across the chest walls. The lung area is abnormal if the “1-2-3” sound is understood. This is the abnormal ‘1-2-3’. Compare this sound to the recording found in the “Whispered Pectoriloquy - Normal” lesson. Stridor is caused by upper airway narrowing or obstruction. It is often heard without a stethoscope. It occurs in 10-20% of extubated patients. Stridor is a loud, high-pitched crowing breath sound heard during inspiration but may also occur throughout the respiratory cycle most notably as a patient worsens. In children, stridor may become louder in the supine position. Causes of stridor are pertussis, croup, epiglottis, aspirations. Monophonic wheezes are loud, continuous sounds occurring in inspiration, expiration or throughout the respiratory cycle. The constant pitch of these sounds creates a musical tone. The tone is lower in pitch compared to other adventitious breath sounds. The single tone suggests the narrowing of a larger airway.These lung sounds are heard over anterior, posterior and lateral chest walls. These sounds can be more intense over lung areas affected by partial obstructions.

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How to Guide

Venipuncture by Prof. D-r Katarina Stavric Centre for Family Medicine

Necessary materials ● Venipuncture set (needle, syringe, vacuum tubes, Vacutainer) or infusion set – depending of what procedure is needed or type of analysis that is performed. ● Single use latex gloves ● Tourniquet (Esmarch) ● Swabs ● Alcohol 70% STEP 1

● Educate the patient ● Taking blood after fasting (does morning coffee, water, juices or evening meal have any influence on the blood taken for the analysis?) ● Why do we administer IV Therapy? STEP 2

● Prepare necessary venipuncture equipment ● Be sure to correctly identify the patient (Name, Surname, hospital number) ● Make correct notes (Who took blood, time, and purpose) ● Explain the procedure to the patient STEP 3

● Preparations EMSA Macedonia Summer School 2013

Course Book EMSS04 ● Put the gloves on ● Disinfect patient’s arm ● Ask him of previous venipunctures or IV therapy ● Explain the procedure to the patient ● Pick up appropriate materials for venipuncture STEP 4

● Set the tourniquet (esmarch) about 10 cm above fossa cubitalis ● Tell the patient to pump the fist three times ● Palpate the veins and pick up the most convenient one (approach, size, depth, direction). Make sure that there are no damage to the skin, scars, infections etc.) ● Rotate the arm slightly if you cannot see the veins. ● Choose the biggest and most convenient vein. STEP 5

● If you cannot find appropriate vein ● Reapply the tourniquet the same way ● Tell the patient to pump the fist three times but watch that he/she do not make hemoconcentration ● Keep the arm on the level lower than the heart 1 to 3 minutes ● Warm the place up (massage) ● Ask for help from the more experienced colleague. STEP 6

● Vena cubitalis mediana – first choice (good approach, protected from sliding) ● Vena cephalica – second choice ● Vena Basilica – third choice, most easily visible, but most easily moved which makes venipuncture harder. ● One must be very careful with venipuncture site because of the risk of damaging some nerve. STEP 7

● Disinfection with 70% alcohol of fos-

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EMSA Macedonia sa cubitalis. If the swab becomes too dirty, repeat the procedure or ask the patient to wash the regia with water and soap before the procedure (after accidents or such) ● Do not palpate (if you do, swab again) ● Disinfect starting from the center (place of the planned venipuncture) to the sides with circular motions. Wait for the alcohol to dry. After that, you can start the venipuncture. ● Use sterile needle or venipuncture set (or I.V. Set) ● Apply the needle at the 15 – 30 degree angle to the vein’s lumen ● If blood starts flowing, that means that you’ve entered the vein. ● Take the blood for the analysis using Vacutainer vacuum tubes (if that was the purpose of venipuncture) STEP 8

● Finishing the procedure ● Release the tourniquet with other hand (it shouldn’t stand longer than one minute) simultaneously with filling the last vacuum tube ● Put the tube at the safe place ● Take swab with 70% alcohol and put it over the needle ● Quickly retract the needle ● Press the puncture site with the swab STEP 9

● Take care of the patient, puncture site and prepare the materials for analysis ● Throw away used materials in thrash bin for medical materials ● Check again tubes and information and send the material for analysis accompanied with proper documentation ● Check the patient for bleeding at the place of the puncture. If bleeding doesn’t stop after 15 minutes continue to apply pressure at the puncture site. EMSA Macedonia Summer School 2013

Course Book EMSS04 â&#x2014;? Thank the patient. â&#x2014;? Wash your hands.

Administering Therapy Preparations for I.V. Therapy is the same as for venipuncture. The procedure is the same and for the needle retraction. After inserting of the needle, it should be fixated and used with I.V. Set or previously prepared syringe with medication. NB: Press the air out of the syringe or I.V. Set before their use The medication is administered after fixation of the needle and releasing of the tourniquet. Watch out! Right after the administration of the medicine there may be swelling at the place of the puncture or nearby. That is a sign that the medicine is administered paravenously because of bursting of the vein or pulling of the needle out of it. In that case, administration of the medicine should be stopped and procedure repeated.

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How to Guide

Cervical Smear & Swabs

by Prof. D-r Katarina Stavric Centre for Family Medicine

ytological abnormalities can be diagnosed by taking a cervical smear. Liquid based cytology is the preferred means of processing samples. Cells can be obtained by applying a brush to the cervix and rotating it whilst maintaining contact. The brush is then placed in a container, containing fixative and sent to the laboratory for examination. To be effective cells from both the ecto and the endo cervix must be included. The optimum time to take a cervical smear is on days 10-20 of a 28 day cycle since there are few polymorphs and mature endocervical cells. If a woman is menstruating this may obscure the endocervical cells. In high risk individuals, however, it may be necessary to take a smear whatever stage of their menstrual cycle. Note: Always perform the following in order: 1. Abdominal examination 2. Speculum 3. Vaginal examination Smears tests should always be done first, followed by swabs then vaginal examination. Communication ● Introduce yourself. ● Explain what you would like to do & why. ● Gain consent for the procedure. ● Request a chaperone ● Reassure the patient that the examination may be uncomfortable but should not be painful (and that if it becomes painful that you will stop.) Equipment ● Cusco (bivalve) speculum – choose an appropriate size ● KY jelly ● Examination gloves ● Bright lamp ● LBC medium ● Cervical brush EMSA Macedonia Summer School 2013

Course Book EMSS04 Position & exposure 1. Ensure that the patient has passed urine 2. Maintaining the patient’s privacy – ask/assist them to remove underwear 3. Lie the patient supine and expose below the costal margins downwards, covering the 4. Pelvic region with a towel or blanket 5. Perform an abdominal examination then reposition the patient by asking her to draw the knees up, putting the heels together to allow the knees to fall apart. General inspection ● Wash hands and put on gloves ● Inspect the vulva looking for: a) Vulval swelling b) Inflammation c) Ulceration d) Warts e) Discharge f) Prolapse Prepare the speculum ● Warm the speculum in warm water (you will not have time to do this in an exam) ● Assemble the speculum ● Using a paper towel or swab, smear a small amount of KY jelly onto the speculum ● Prepare the cervical brush, LBC kit and any other swabs (microbiological and Chlamydia Swabs.) Insert the speculum ● Inform the patient that you are about to insert the speculum ● Part the labia with the fingers of the left hand. ● Ensure the speculum is closed before insertion to prevent catching on the vaginal wall ● Insert the speculum sideways, until the tip has passed the labia, then rotate it so that the clasp is at 12 O’clock ● Gently open the speculum and lock it by turning the screw on the clamp once the cervix is visualised ● Inspect the cervix and vagina for ulcers, papillomatous lesions, warts etc. Taking the smear ● Insert the long bristles of the brush into the endo-cervical canal deep enough to allow the shorter bristles to fully contact the ecto-cervix. ● Push gently and rotate the broom in aclockwise direction 5 times ● Rinse the broom in the LBC medium by pushing the broom into the bottom of the vial 10 times forcing the bristles apart. ● As a final step, swirl the brooms vigorously to further release material (examining the broom for residual material before disposing of the broom into clinical waster receptacle.)

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EMSA Macedonia Taking an endocervical swab (Chlamydia Trachomatis & Neisseria Gonorrhoeae) Using unisex specimen collection kit (purple) 1. Remove excess mucus from the cervix and surrounding mucosa using the cleaning swab (white shaft) 2. Discard this swab 3. Insert the specimen collection swab (blue shaft) into the endocervical canal 4. Gently rotate the swab clockwise for 10-30 secs in the endocervical canal 5. Withdraw the swab carefully avoiding any contact with the vaginal mucosa 6. Remove the cap from the swab specimen transport tube & immediately place the specimen swab into the transport tube 7. Carefully break the swab shaft at the score-line 8. Re-cap the tube tightly Taking High Vaginal Swabs: Using standard culture (wound) swab 1. Remove the collection swab from the packaging 2. Insert the swab into the fornices, avoiding the lower vaginal walls 3. Remove the swab from the vagina taking care not to touch the speculum or perineum on exit 4. Insert the swab into the collection tube ensuring the swab enters the culture medium fully and the cap is sealed ● Remove the speculum ● Remove the speculum under direct supervision ● Avoid closing the speculum until it is clear of the cervix ● Ensure the patient is comfortable and dignity is maintained ● Allow/assist them to dress. ● Complete appropriate specimen forms and enter the patient details on the specimen tubes according to local protocols. Send LBC (PAP) smears to CYTOLOGY Swabs for chlamydia trachomatis to VIROLOGY Swabs for Neisseria gonorrhoeae to MICROBIOLOGY Culture swabs for fungal or bacterial examination to MICROBIOLOGY

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Course Book EMSS04

How to Guide

Rectal Examination by Prof. D-r. Katarina Stavric Centre for Family Medicine

There are multiple positions that you can ask your patient to stand or lay. These include: I) Standing position: patient standing with toes pointing in, then leans over a table II) Knee to chest: patient with laying on table facing down with knees up to chest bent Both the standing and knee to chest positions are most ideal for the prostate exam IV) Left lateral decubitus (Sims position): patient lays on left side with left hip/leg straight and the right hip/knee is bend

Inspection of Anus Look for external hemorrhoids, fissures (90% of time they are located in midline posteriorly), skin tags, warts or discharge

Digital rectal examination An examination in which a doctor inserts a lubricated, gloved finger into the rectum to feel for abnormalities.

Techniques Of Examination Many examiners prefer to do a rectal examination on an ambulatory patient when he is standing, with hips flexed and upper body resting across the examining table. This position tends to flatten the buttocks and make the anal canal and rectum more accessible to the examining finger. For the non-ambulatory patient, the lateral posi-

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EMSA Macedonia tion is necessary and some examiners may prefer to use it routinely. In this situation, ask the patient to lie on his left side with his right hip and knee somewhat flexed, his buttocks close to the edge of the examining table near you. Adjust the lighting for good visualization of the anus and surrounding area. Put a glove on your right hand and lubricate the index finger. With your left hand, spread the buttocks apart. Palpate Rectum and Prostate 1. Use a small amount of lubricant on the index finger and ask the patient to take a deep breath and insert the finger facing down (6 o’clock position) 2. Appreciate the external sphincter tone then ask the patient to bear down and feel for tightening of the sphincter 3. Palpate the prostate gland. Note the following: 1. Approximate size of the prostate gland (normally about the size of a walnut, 2-3 cm but wider at the top) 2. Feel for tenderness (prostatitis) 3. Feel for nodules or masses 4. Palpate the rectal wall starting from the 6 o’clock position clockwise to the 12 o’clock position. Then return to the 6 o’clock position and palpate the other half of the rectal wall feeling for masses, nodules and tenderness.

Occult Blood Test Check any fecal material on your gloved finger for occult blood with a guaiac kit. Anal Fissure - An anal fissure, also called an anorectal fissure, is a linear split or tear in the lining (“anoderm”) of the lower anal canal. Most anal fissures happen when a large, hard stool overstretches the anal opening and tears the delicate anoderm. Less often, anal fissures develop because of prolonged diarrhea, inflammatory bowel disease or sexually transmitted diseases involving the anorectal area. Acute (short - term) anal fissures are usually superficial and shallow, but chronic (long - term) anal fissures may extend deeper through the anoderm to expose the surface of underlying muscle. An anal fissure is a very painful oval ulceration of the anal canal, most commonly found midline posteriorly, less commonly in the midline anteriorly. Its long axis lies longitudinally. EMSA Macedonia Summer School 2013

Course Book EMSS04 Inspection may reveal a â&#x20AC;&#x153;sentinelâ&#x20AC;? skin tag just below it, and gentle separation of the anal margins may reveal the lower edge of the fissure. The sphincter is spastic; the examination painful. Local anesthesia may be required. Anal abscess - An anal abscess is a swollen, painful collection of pus near the anus. Most anal abscesses are not related to other health problems and arise spontaneously, for reasons that are unclear. They originate in a tiny anal gland, which enlarages to create a site of infection under the skin. In the United States, more than half of all anal abscesses occur in young adults between the ages of 20 and 40, and men are affected more often than women. Most anal abscesses are located near the opening of the anus but rarely can occur deeper or higher in the anal canal, closer to the lower colon or pelvic organs.

Anorectal Fistula An anorectal fistula is an inflammatory tract or tube, one end of which opens into the anus or rectum, while the other end opens onto the skin surface, as shown here, or into another viscus. An abscess usually antedates such a fistula. Look for the fistulous opening or openings anywhere in the skin around the anus.

External Hemorrhoid Hemorrhoids are varicose veins. External hemorrhoids originate below the anorectal line and are covered by anal skin. When uncomplicated they may not be visible at rest, but a thrombosed hemorrhoid presents as a painful, bluish, shiny, ovoid mass at the anal margin. Flabby or fibrotic skin tags may mark the location of previously thrombosed or inflamed hemorrhoids.

Internal Hemorrhoid Internal hemorrhoids originate above the anorectal junction and are covered by mucous membrane, not skin. They are not visible unless they prolapse through the anus, nor are the soft swellings normally identifiable by palpation. Proctoscopic examination is usually required for diagnosis.

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EMSA Macedonia Pilonidal Cyst & Sinus A pilonidal cyst is a fairly frequent, probably congenital abnormality located in the midline superficially identified by the opening of a sinus tract. This opening may exhibit a small tuft of hair and be surrounded by a halo of erythema. Although generally asymptomatic except perhaps for slight drainage, abscess formation and secondary sinus tracts may complicate the picture. Rectocele A rectocele is formed by the anterior and downward bulging of the posterior vaginal wall together with the rectum behind it. To identify it, spread the patientâ&#x20AC;&#x2122;s labia and ask her to strain down. Prolapse Of The Rectum On straining for a bowel movement, the rectal mucosa, with or without its muscular wall, may prolapse through the anus, presenting as a doughnut or rosette of red mucosa. A prolapse involving only mucosa is shown here. When the entire bowel wall is involved, the prolapse is larger; and circular rather than radiating folds are seen.

Abnormalities Of The Prostate Normal Prostate As palpated through the anterior rectal wall, the normal prostate is a rounded heart-shaped structure about 2.5 centimeters in length, projecting less than 1.0 centimeter into the rectal lumen. The median sulcus can be felt between the two lateral lobes. Only the posterior surface of the prostate is palpable. Anterior lesions, including those that may obstruct the urethra, may not be detectable by physical examination. Benign Prostatic Hypertrophy A very common condition in men over 50 years of age, benign prostatic hypertrophy presents as a firm smooth symmetrical and slightly elastic enlargement of the gland. It may bulge more than a centimeter into the rectal lumen. The hypertrophied tissue tends to obliterate the median sulcus. Carcinoma Of The Prostate A hard irregular nodule, producing asymmetry of the gland and a variation of its consistency, is especially suggestive of EMSA Macedonia Summer School 2013

Course Book EMSS04 carcinoma. Prostatic stones and chronic inflammation can produce similar findings, and differential diagnosis often depends upon biopsy. Later in its course, the carcinoma grows in size, obliterates the median sulcus and may extend beyond the confines of the gland producing a fixed, hard, irregular mass. Symptoms Although all four anal disorders cause some type of anal discomfort or pain, other symptoms vary, depending on the specific anal problem. For anal fissure, symptoms may include: pain in the anal area, often described as sharp, searing or burning, and usually triggered by a bowel movement, mild rectal bleeding, typically a small amount of bright red blood with a bowel movement or on the toilet paper. For anal abscess, symptoms include: a firm, tender mass or swelling in or around the anal area, which may become large, occastionally fever, chills and a generally sick feeling. For an anal fistula, signs and symptoms may include: mild pain around the anus, centered in an area where an old anal abscess has either drained spontaneously, or has been opened surgically by a doctor. Persistent drainage of blood, pus or foul - smelling mucus from the anal area. Symptoms of a recurrent anal abscess (see above), which may develop if the external opening of the fistula becomes clogged and the old abscess reactivates. For thrombosis of an external hemorrhoid, the signs and symptoms include: A firm and usually painful swelling at the anal orifice, occasionally bloody discharge, if the surface of the hemorrhoid breaks down.

Diagnosis Once you have described your symptoms, your doctor will ask questions about your medical history and lifestyle that will help in evaluating your anal problem. Depending on your symptoms, the doctor may ask about: ● Your bowel habits, especially any history of constipation ● Your medical history, including any history of bleeding disorders, episodes of rectal bleeding, inflammatory bowel disease, sexually transmitted diseases or radiation treatment for cancer ● Your use of prescription or nonprescription medications that may increase the risk of bleeding ● Whether you practice anal intercourse or have any history of anal trauma Next, your doctor will perform a physical examination of your abdomen, followed by an external examination of your anal area and a digital (finger) rectal examination. Usually your doctor will also perform anoscopy (insertion of a tube like instrument into the anus to look

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EMSA Macedonia inside the anal canal) and sigmoidoscopy (a short telescope to examine the rectum and lower colon). Expected Duration How long anal disorders last varies: Anal fissure - Painful anal fissures can be a recurrent problem in people who suffer from repeated episodes of constipation. Fortunately, superficial fissures usually heal quickly with medical treatment, and most symptoms disappear within a few days to a couple of weeks. Anal abscess - An anal abscess sometimes drains on its own, although it is always safer for a doctor to evaluate the problem. If the abscess does not drain on its own, the doctor may incise and drain the abscess. After an abscess is drained, the pain is usually immediately better. An anal abscess often turns into an anal fistula even with appropriate treatment. Anal fistula - Without treatment, an anal fistula may continue to ooze blood or pus for prolonged periods. Thrombosed external hemorrhoid - Usually the body will slowly reabsorb the clot in such a hemorrhoid, and the pain and swelling will slowly go away over a period of days to a couple of weeks. Prevention You may be able to prevent anal fissures by preventing constipation. To do this, soften your stool by gradually adding more fiber to your diet, and by drinking 6 to 8 glasses of water daily. Commercially available fiber supplement powders work well. Although it is not always possible to prevent other types of anal disorders, you may be able to decrease your risk for these illnesses by: ● Using gentle techniques to clean the anal area ● Keeping the anal area dry by changing underwear frequently and using powder to absorb moisture ● Always using a condom if you practice anal intercourse ● Never inserting any foreign object into the rectum Treatment A doctor must diagnose the four anal disorders described here. Once the diagnosis is made, your treatment may or may not involve surgery, depending on the specific disorder. If surgery is necessary, your doctor will use whatever type of anesthesia is appropriate to help prevent you from feeling pain in this very sensitive area. Anal fissure - For an acute fissure, your doctor may recommend that you follow the suggestions for relieving constipation that are described in the Prevention section above. He or she also may tell you to apply a medicated ointment to the fissure, and to soak the anal area in warm water for 10 to 15 minutes several times a day (“sitz bath”). For chronic fissures, surgery can correct the problem in more than 90% of cases. Anal abscess - An anal abscess must be opened or lanced by a doctor to drain the pus. This procedure is called incision and drainage, or I&D. This usually can be done as an outpatient EMSA Macedonia Summer School 2013

Course Book EMSS04 procedure, especially if you are young and generally healthy, and your abscess is close to the anal opening. Anal fistula - Surgery to unroof the fistula track (“fistulotomy”), is the most effective therapy. Your doctor opens the infected canal and scrapes away any remnants of the old anal abscess. The wound is left open to heal from the bottom up. If the fistula is associated with Crohn’s disease, treatment is directed toward the Crohn’s disease with anti-inflammatory medications combined with an antibiotic. Thrombosed external hemorrhoid - Usually this will slowly disappear on its own. The process can be hastened by taking a fiber supplement to soften the stool, as well as by taking frequent warm water soaks (“sitz baths”). If the hemorrhoid is unusually painful, the doctor may carry out a limited operation under local anesthesia to remove the clotted hemorrhoid.

When To Call a Professional Call your doctor promptly whenever you have rectal bleeding or any bloody discharge from the anus. Even if you have been treated for a bleeding fissure in the past, it is always safer for your doctor to determine the best course of action. This is especially true if you are over age 40, when there is an increase in the risk of rectal bleeding from colorectal cancer and other serious digestive diseases. Also, call your doctor if you have: Severe pain in the anal area; a tender mass or swelling near the anus, with or without a fever, pus or a foul-smelling discharge from the anus, discomfort or tightness in the anal area that interferes with bowel movements. Prognosis In most cases, the prognosis is excellent. Almost all acute fissures heal quickly with conservative treatment, and almost all fistulas and chronic fissures can be corrected with surgery. Appropriate treatment of anal strictures will allow stool to pass easily and comfortably. Most anal abscesses heal after being drained by a doctor. Some develop into anal fistulas. If a fistula does complicate the healing of an abscess, a fistulotomy will totally eliminate both the fistula and any remaining abscess in most patients.

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Современ Третман на Ректалниот Карцином by Ass. D-r. Svetozar Antovic University Clinic of Digestive Surgery Medical Faculty - Skopje

еројатно во ниту еден друг случај од онколошката пракса, не се продуцира толку научно знаење, како што е карциномот на ректумот. Ова и не е толку зачудувачки ако се знае дека карциномот на ректумот е на трето место и по инциденцата и по морталитетот и кај мажите и кај жените. Токму заради тоа, ректалниот кацином нуди се повеќе можности за унапредување не само на преживувњето туку и на намалување на колатералните штети од неговото лекување, повеќе од било која друга малигна болест. Сепак, натпреверувачкиот притисок кој го прават истражувањата на различните специјалности, а кои се заеднички вклучени во лекувањата на ова заболување, создаваат многу неодговорени прашања, без доволно цврсти докази за бенефитот од нив со што би можеле да ги вклучиме во стандардните протокли за лекување на овие пациенти, а врз медицината заснована на докази. Примери за вакви подрачја на конфузија се: • Радиотерпијата • Долг или краток курс на истата • Да биде комбинирана со хемотерапија или не • Каква да биде комбинацијата на двете • Критериуми за употреба и селекција на современите дијагностички техники и методи • Треба ли ректалниот карцином да се оперира без предходно пациентот да биде евалуиран со Магнетна Резонанца • Појавата на феноменот на комплетен клинички одговор на терапија Иако современиот третман на ректалниот карцином денеска се третира со мултидисциплинарен пристап, нема збор дека хирургијата и натаму е камен темелник во неговото лекување. Без разлика на секоја друга употребена нео или адјувантна терапија, доколку хирургијата закаже во својата перфектност, тогаш шансите за излекување драстично се намалуваат. Најзагрижувачкиот аспект на напредокот во лекувањето на ова заболување во 21 век преставува вртоглавиот скок на цената на лекување ако се земат во обзир новите хемио и радиотераписки процедури. Практично предоперативната хеморадиотерапија денеска EMSA Macedonia Summer School 2013

Course Book EMSS04 се смета за нов Европски стандард, а тоа прави цената на лекување да расте до такви висини кои се неодржливи за многу европски држави, а да не говориме за земјите во развој, каде што спаѓа и Република Македонија. Токму заради тоа со нетрпение се чекаат студиите кои се веќе во тек, а кои треба да дадат одговор на тоа кои пациенти треба, а кои не да бидат предоперативно третирани. Изгледа се поизвесно дека правилното предоператвно поставување на пациентот особено со Магнетна Резонанца, може да даде одговор на ова прашање. Преоперативна обработка и клинички стејџинг Јасно е дека секој пациент преоперативно мора индивидуално да се разгледува во рамките на мултидисциплинарниот тим и за него индивидуално да се испланира најсоодветниот начин на третман. Меѓу тоа ваквата обработка не може да биде произволна, туку по точно утврден протокол, а во кој некои испитување се од есенцијална важност: • КТ на абдомен, карлица и граден кош • Трансанална ендоскопска ултрасонографија • Магнетна резонанца Компјутеризираната томографија денска се смета за помалку сензитивна и специфична во евалуацијата на локалниот наод односно туморската инвазија и позитивните лимфни жлезди, отколку ТЕУ или МР. Она на што ни дава одговор денеска се секундарните метастаски депозити во белите дробови или црниот дроб, двете најчести места на метастазирање на овој карцином. ТЕУ има најзначајно место во евалуацијата на особено ниските тумори на ректумот и посебно туморите со Т1 или Т2 големина. Таа има можност циркуларно да ги прикаже сите слоеви на ѕидот на ректумот и со голема точност од преку 90 проценти да каже кој од овие слоеви е пробиен од страна на туморот. Покрај ова е и одлична за детекција на зголемените лимфни јазли во мезоректумот, а кои ако се поголеми од 1 цм се суспектни за малигнитет и дополнително може трансанално да бидат биопсирани за ова да се потврди. Во Англија веќе дого време се води еден голем мултицентричен проект MERCURY кој има за цел да ја процени важноста на Магнетната Резонанца како метода во евалуација на зафатеноста на циркумферентната маргина од примарниот тумор, а што е во директна корелација со тоа дали пациентот ќе прими или нема предоперативна радиохемотерапија. Сегашните резултати покажуваат дека МР може со точност од околу 91% да даде одговор на ова прашање, а со тоа и да се заштедат огромни Нормален ѕид на ректумот Т3 тумор со лимфен јазол во средства со самото тоа што мезоректумот

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EMSA Macedonia неоадјувантната терапија нема да се дава на сите пациенти како досега кои се во стадиум 3 и 4 на болеста, туку само на оние на кои тоа им е потребно. Преоперативна радиохемотерапија Накратко, денешните современи протоколи предвидуваат овој вид на терапија да се даде кај сите пациенти кои се со големина Т3 или Т4 на туморот особено ако се лоцирани во средната или долната третина на ректумот па дури и кај некои Т2 тумори кои со својот раст ги инвадираат леваторите или сфинктерниот апарат на ректумот. Целта на оваа треапија можеме да ја дефинираме како намалување на примарниот тумор со што некои нересектабилни тумори би станале ресектабилни и второ да се добие чиста циркумферентна маргина со што значајно би Магнетна резонанца на ректумот се намалил потенцијалот за локален рецидив. која јасно покажува слободна Досегашните студии покажуваат дека влијанието на овој вид терапија во 5 годишното преживување циркумферентна маргина на пациентите е многу мало, но сепак ако се знае дека со оваа терапија се намалува можноста за рецидив за околу 50 проценти, а кој рецидив е врзан за многу тешки симтоми кај пациентите, тогаш е сосема јасен бенефитот од неа. Предностите на оваа треапија а во однос на постоперативната се: • Намалување на локалниот рецидив • Намалување на големината на примарниот тумор • 10 проценти на целосен клинички одговор на оваа терапија • Помал процент на анастомотични стенози • Помала севкупна токсичност • Пациентите подобро ја поднесуваат Единствената негативност е во тоа што има можност за прекумерно третирање на оние пациенти кои не требало да ја добијат, а сепак ја добиле заради грешки во клиничкиот стејџинг на болеста и поголем процент на незараснување на оперативните рани. Режимите на оваа терапија се надвор од рамките на овој текст, но накратко да спомнам дека постојат кратки и долги курсеви на радиотерапија или редиохемотерапија која денеска се повеќе се применува во комбинација со 5 флуороурацил, Леуковорин, Оксалиплатин, Иринотекан, Капецитабин, Бевацизумаб итн. Најчесто се употребува краток курс на радиотерапија со 25 Gy поделена во 5 фракции EMSA Macedonia Summer School 2013

Course Book EMSS04 од по 5 Gy дадена за 5 дена по што по една недела следи хируршко одстранување на туморот. Но има како што кажавме многу различни протоколи кои се уште се во фаза два или три од нивното клиничко испитување и со нетрпение се очекува кој од нив ќе се наметне како протокол на избор. Хируршко лекување Сите хируршки процедури кои денес постојат за лекување на ректалниот канцер може да се поделат во две големи групи и тоа • Сфинктер презервирачки процедури, > 80% - Предна ресекција на ректумот, ниска или ултраниска - Интерсфинктерна ресекција со колоанална анастомоза • Сфинктер непрезервирачки процедури, < 20% - Абдоминоперинеална ексцизија на ректумот Она што, кај било која од овие процедури треба да се направи, е тоталната мезоректална ексцизија (ТМЕ) која денес представува златен стандард во хируршкиот третман на ректалниот карцином. Овој концепт е развиен во 1982 година од страна на професорот Bill Heald и прави револуционерен скок како во намалувањето на локалниот рецидив на болеста, 5 годишното преживување така и зачувување на функцијата на автономните нерви на малата карлица кои се поштедени при оваа процедура, а со што значително се намалува процентот на проблеми со мочниот меур и сексуалните функции кај пациентите. Во основа опфаќа ресекција на ректумот со целиот негов мезоректум движејќи се по таканаречниот Holy Plane или ембрионалните патишта околу мезоректумот, а тоа е висцералната фасција на ректумот. Дека е навистина важна покажува и фактот дека

Добро - Степен 1

Средно - Степен 2

Лошо - Степен 3

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EMSA Macedonia хирурзи кои се тренирани за оваа процедура имаат процент на локален рецидив помал од 10% додека оние кои не се тренирани за оваа техника имаат процент на локален рецидив поголем од 40 %. Се повеќе се смета дека еден конечен патохистолошки документ треба да содржи и критериум на оцена за тоа како е направена ТМЕ, односно патологот да направи евалуација на хируршкиот препарат и соодветно да го оцени бидејЌи ова е во директна корелација со преживувањето на пациентот и локалното рецидивирање на болеста. Денес за тоа служат MERCURY критериумите за оценка на ТМЕ. Значи денеска современ третман на овој карцином од хируршки аспект е незамислив доколку не се направи добра тотална мезоректална ексцизија или за туморите од горната третина парцијална мезоректална ексцизија 5 цм под туморот. Било која редиохемотерапија е апсолутно неважна доколку се потфрли во хирурШкото лекување на карциномот на ректумот. Оттука и најважното место на хирургот во мултидициплинарниот тим кој идеално ги лекува овие пациенти.

EMSA Macedonia Summer School 2013

Course Book EMSS04

Торакална Дренажа by D-r. Borislav Kondov Medical Faculty - Skopje

оракална дренажа претставува хирушка интервенција на обезбедување на механичка комуникација на плевралниот простор со надворешната средина . Пласирањето може да биде од дијагностички или терапевски цели. Во плевралниот простор нормално владее негативен притисок од -5 мм живин

столб. Дијагностичка улога на торакалната дренажа: Во зависност од содржината која ке се добие при дренажниот процес можеме да донесеме дефинитивена дијгноза. Индикации: Во плевралниот простор нормално владее негативен притисок од -5 мм живин столб понизок од нормалниот атмосверски притисок. Нарушување на херметичката плеврална бариера доведува до изедначување на притисокот во плевралниот простор со атмосверскиот притисок и колабирање на белодромниот паренхим. Оваа состојба претставува Пневмоторакс. Првичниот третман на ваквите состојби се состои во пласирање на торакален дрен. Друга ургентна состојба при која може успешно да се реши сопласирање на торакален дрен претставува хематоторакс. Тоа е состојба при која во плевралниот простор има одредена количина на крвава содржина. Целта на торакалниот дрен е да овозможи евакуација на крвавата содржина од плевраниот простор се со цел да се овозможи реекспанзија на белодробниот паренхим. За поголема ефикасност на овој процес неопходно е да се конектира торакалниот дрен со дренажна пумпа. Изведување на торакална дренажа Торакалната дренажа се изведува во стерилни услови. Се инјектира локален анестетик во долниот раб на горното ребро. Потоа се прави инцизија на кожата во висина на петиот меѓуребрен простор и со тапо препарирање се раздвојуваат интеркосталните мускули. Одкако ке се направи доволно широк канален простор, се пласира торакалниот дрен со помош на прав пеан. Одржување на торакална дренажа Торакалната дренажа претставува исклучително значајна и моќна терапевска метода која во краток временски интервал овозможува ослободување на белодробниот кавитет при состојби на ликвидоторакс, хематоторакс или хило торакс. Исто така може да има и извонредно значајна улога и при состојби на пнеумоторакс овозможувајќи

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EMSA Macedonia реекспанзија на белодробниот паренхим. Меѓутоа торакалната дренажа претставува и важен индикатор за состојбите сто се случуваат во торакалната празнина. Зголемена продукција може да укажува на динамички промени кои што може да захтеваат и промена на режимот на лекување. Доколку при дренажниот процес иницијално се добие волумен на крв од 1000 мл при хематоторакс , или има продукција по 150мл на час во наредните три часа (вкупно 450мл) тоа е ургентна состојба која претставува индикација за отворена торакална процедура (итна торакотомија). Вадење на торакална дренажа Одкако ке ја постигнеме крајната цел или ке се постигнат максималните можности на торакалната дренажа се пристапува кон процес на нејзино отстранување. За соодветна проценка неопходно е претходно да се направи контролна ренген графија за да се евалуира ефектот од дренажниот процес. Покрај контролна ренген графија исто така важен параметар ни претсавува и динамиката на продукција на евакуираната содржина (освен при состојби на пнеумоторакс). Доколку продукцијата е помалку од 50 мл во последните 24 ч. и доколку ренгнолошкиот наод е уреден , може да се пристапи кон вадење на торакалниот дрен.

EMSA Macedonia Summer School 2013

Course Book EMSS04

Principles Of Musculoskeletal Injuries by Ass. D-r. Igor Kaftandziev Medical Faculty - Skopje

Anatomy and physiology of the Musculoskeletal System Key terms Skeleton: the bones of the body collectively. Adults have 206 bones Joint: the site of junction or union between bones Tendon: a fibrous cord of connective tissue continuous with the fibbers of a muscle and attaching the muscle to bone or cartilage. Ligament: a band of fibrous tissue connecting bones or cartilages, serving to support and strengthen joints. Articular cartilage: The cartilage covering the articular surfaces of the bones forming a synovial joint. Also called arthrodial cartilage, diarthrodial cartilage, investing cartilage Muscles: an organ which by contraction produces movement There are three types of muscle: involuntary, voluntary, and cardiac, composed respectively of smooth, striated, and mixed smooth and striated tissue. Anatomy of a long bone The long bones are longer than they are wide. They are divided into five types: long, short, flat, irregular and sesamoid. Long bones grow primarily by elongation of the diaphysis (the central shaft), with an epiphysis at each end of the growing bone. The ends of epiphyses are covered with hyaline cartilage (articular cartilage). The metaphysis is the wider portion of a long bone adjacent to the epiphyseal plate. This is the part of the bone that grows during childhood; as it grows, it ossifies near the diaphysis and the epiphyses. At roughly 18 to 25 years of age, the metaphysis stops growing altogether and completely ossifies into solid bone. At the cessation of growth, the epiphyses fuse to the diaphysis, thus obliterating the intermediate area known as the epiphyseal plate or growth plate. The outside of the bone consists of a layer of connective tissue called the periosteum. The outer shell of the long bone is compact bone, below which lies a deeper layer of cancellous bone. The interior part of the long bone is called the medullary cavity with the inner core of the bone cavity being composed of yellow marrow in adults, and red marrow in young children. The skeletal system serves many important functions. It provides the shape and form for our bodies in addition to support and protection. It also allows bodily movement, produces blood for the body, and stores minerals.

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EMSA Macedonia Joints Joint is a site of the junction or union of two or more bones of the body; its primary function is to provide motion and flexibility to the frame of the body. Some are immovable, such as the sutures where segments of bone are fused together in the skull. Others, such as those between the vertebrae, are gliding joints and have limited motion. However, most joints allow considerable motion. The most common type are the synovial joints, which have a complex internal structure, composed not only of ends of bones but also of ligaments, cartilage, the articular capsule, the synovial membrane, and sometimes bursae. Joints can also be classified by the type of tissue connecting the bones of the joint. Fibrous Joints: The bones of these joints are connected by fibrous ligaments only. Cartilaginous Joints: The bones involved in cartilaginous joints are joined by some type of cartilage. Synovial Joints: These joints are freely moveable and are characterized by a joint cavity between the bones that has a synovial membrane and is lubricated with synovial fluid. Joints can be classified by how much movement they allow. Synarthroses: Immovable joints. Specific examples of synarthroses are suture joints (the joints in the skull) and synchondroses (the type of joint found in growth plates). Amphiarthroses: Slightly moveable joints. A specific example of an amphiarthrosis is a symphysis (such as the joint between two vertebrae). Diarthroses: Freely moveable joints. Specific examples of diarthroses are typical synovial joints such as the shoulder and wrist.

Skeleton The human skeleton is composed of both fused and individual bones supported by ligaments, tendons, muscles, and cartilage. It is a complex structure with two distinct divisions: the axial and the appendicular skeletons. The axial skeleton consists of the 80 bones along the central axis of the human body. It is composed of: the human skull, the ossicles of the middle ear, the hyoid bone of the throat, the rib cage (including the sternum), and the vertebral column. The axial skeleton and the appendicular skeleton together form the complete skeleton. The word “axial” is taken from the word “axis” and refers to the fact that the bones are located close to or along the central axis of the body. The appendicular skeleton is composed of 126 bones in the human body. The word “appendicular” is the adjective of the noun appendage, which itself means a part that is joined to something larger. Functionally, it is involved in locomotion (lower limbs and pelvic girdle) of the axial skeleton and manipulation of objects in the environment (upper limbs and pectoral girdle) Throughout life, bones constantly change through a process of absorption and formation called “remodeling.” As we age, the balance between bone absorption and bone formation changes, resulting in a loss of bone tissue. The mineral content of bones decreases, so that bones become less dense and more fragile. As bones lose mass, osteoporosis develops, affecting both women and men. In the spine, EMSA Macedonia Summer School 2013

Course Book EMSS04 osteoporosis can lead to crush fractures of the vertebrae, resulting in a “dowager’s hump.” Osteoporosis is also responsible for almost all hip fractures in older men and women. The chemistry of cartilage, which provides cushioning between bones, changes. With less water content, the cartilage becomes more susceptible to stress. As cartilage degenerates, arthritis can develop. Ligaments, connective tissues between bones, become less elastic, reducing flexibility.

Injuries to the Musculoskeletal System The injuries of the musculo-skeletal system for educational purposes will be divided in three sections: injury to the bone, injury to the joint and soft tissue injury. In nature these injuries are almost never isolated. A fracture is dissolution of bony continuity with or without displacement of the fragments. It is always accompanied by soft tissue damage of varying degrees; there are torn vessels, bruised muscles, lacerated periosteum, contused nerves. Sometimes there are injured internal organs and lacerated skin. The trauma to soft tissue must always be taken into consideration and is often vitally more important than the fracture itself. Etiology Of Fractures Trauma. By the mechanism of injury fractures can be sustained in a high energy trauma (motor-vehicle accidents, fall from hight, industrial accidents) or low energy trauma (simple fall on outstretched hand, fall on hip). Obtaining the mechanism of injury is of paramount importance because some injury patterns are predictable. The severity of injury correlates with the amount of energy transmitted to the tissues Overuse. Repetitive motion can tire muscles and place more force on bone. This can result in stress fractures.. Stress fractures are tiny cracks in a bone. Stress fractures are caused by the repetitive application of force, often by overuse — such as repeatedly jumping up and down or running long distances.Stress fractures are most common in the weight-bearing bones of the lower leg and foot. Track and field athletes are particularly susceptible to stress fractures, but anyone can experience a stress fracture. Pathologic: fracture of weakened or diseased bone. Osteoporosis is the most common disorder that weakens bones and makes them more likely to break.

Extrinsic Causes The forces that cause fractures can be: Direct- when a bone is broken at the area of impact (contact sports, defence injuries) Indirect-when a bone is broken away from area away from the point of impact. This happens because the force is transferred from the point of impact then along the limb until the force comes across a weak bone or a weak spot in a bone. Example: Fall on outstretched hand can result in collar bone fracture). Abnormal muscular contraction-A fracture caused by sudden contraction of a muscle. This can cause pieces of bone being pulled away from where the muscle is attached. Example: electrocution, epilepsy.

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EMSA Macedonia By the direction of the force there are bending, shearing, compression, torsion, tension forces and combination of the above. Bending forces Bending fractures occur when force is applied to a specific focal point on a bone to the extent that the traumatic force overcomes the elastic limit of the bone diaphysis. The initial effect of a bending force is a cortical break opposite the site of the trauma. The periosteum will remain intact on the side of the force while tearing over the fracture on the opposite side. With additional force the entire bone snaps, with attendant tearing of vascular and soft tissue structures within or on the diaphysis. Bending fractures are generally oblique or transverse, or they may have a butterfly fragment. (Example: A patient running across a field steps into a hole with the leg; the edge of the hole is a fulcrum producing a bending fracture of the midshaft tibia.) Torsional forces Torsional fractures occur when a twisting force is applied to the long axis of a bone. Usually this is a result of one end of a bone being placed in a fixed position while the other end of the bone is forced to rotate. The resulting fracture will be a very long spiral with sharp points and often sharp edges. It is possible for the sharp points or edges to compromise soft tissues or to cut through the skin and result in an open fracture. Torsional forces generally result in short or long spiral fractures. (Skiing accident) Compression forces Compressive forces along the long axis of a bone may force the smaller diaphyseal or metaphyseal portion of a bone to impact into the larger epiphysis: bony substance is thereby crushed. Similarly a compressive force directed along the axis of the spine may result in collapse of a vertebral body. For compressive force to result in fracture, one end of a bone must be in a fixed position while the other end is forced toward the fixed end. Compressive forces result in impacted fractures or compression fractures. (Fall from hight- compressive fracture of lumbar spine) Shearing forces A shearing fracture is caused by a force transmitted along the axis of a bone, which is then transferred to a portion of the same bone that lies peripheral to the axis or across a joint to other bones that are not protected by the axis of the bone. The force shears off that bony portion unable to continue transmission of the force along the axis. The fracture line in a shear fracture will be parallel to the direction of the applied force. Shearing forces result in the fracture of bony prominences not placed along the direct axis of a diaphysis. (Vertical shear fracture of pelvis) Tension forces Axial tension can result from contraction of a muscle at its point of attachment on a bone. For tensile force to result in fracture, one end of a bone must be in a fixed position while the other end is forced away from the fixed end. This will create a separation fracture. Common areas for this to occur include the tibial tuberosity, greater trochanter, and olecranon.

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Course Book EMSS04 Intrinsic Causes Fractures due to muscular contraction Fractures caused by violent contraction of a muscle are called avulsion fractures. They may occur because of violent isometric contraction but are associated more commonly with trauma that results in forceful muscular shortening. Example: electrocution, epilepsy. Avulsion fractures affecting bony prominences that serve as the major origin or insertion of a muscle are seen routinely. The processes commonly avulsed include the acromion, scapular tuberosity, greater humeral tubercle, olecranon, ischial tuberosity, greater trochanter, tibial tuberosity, and the calcaneus of the fibular tarsal bone. Pathologic fractures Pathologic fractures occur because of underlying bony or systemic disease that causes one, many, or all bones of patientâ&#x20AC;&#x2122;s skeletal system to be abnormal and thus more susceptible to fracture. Pathologic fractures may occur from any type of trauma: bending force, torsional force, compressive force, or shearing force. Often the only force necessary to cause fracture is the patientâ&#x20AC;&#x2122;s weight; thus, spontaneous fracture occurs without overt trauma. Pathologic fracture may occur through any of the following types of bony pathology: neoplasia, bone cysts, osteoporotic bone, nutritional hyperparathyroidism, localized bone infection (osteomyelitis), osteoporotic bone caused by disuse following prolonged external fixation or removal of a rigid internal device A pathologic fracture can occur in any bone, in any location within a bone, and take any shape. The diagnosis of underlying pathology is usually of more importance than immediate bone fixation. Once the pathologic basis for the fracture has been diagnosed and specific corrective measures initiated, the fracture or fractures can be treated. Treatment of all pathologic fractures, including those due to neoplasms, can be successful.

Classification Of Fractures By Type Fractures are classified into many types based on the severity of the fracture, whether it communicates through the skin, the shape of the fracture line, or the anatomical location of the fracture within an individual bone. All systems are compatible and of necessity overlap. Incomplete Fractures An incomplete fracture implies that a bone has not completely lost continuity; some portion of the bone remains intact. There are several types of incomplete fractures. Greenstick fracture As the name implies, a greenstick fracture resembles the break that results when a supple green branch of a tree is bent and breaks incompletely. Usually the side opposite the bending force fractures completely, while the side under the force remains intact. In the immature animal with similarly supple elastic bone, a bending force will produce the incomplete fracture. Since a portion of the bone cortex remains intact, this fracture cannot override and result in limb shortening; however, the limb may deform along its axis at the point of the bending force

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EMSA Macedonia Fissure fracture Cracks or fissure lines will occur when direct trauma is applied to any long or flat bone. Generally the fissures are formed in one cortex of the bone and are covered by an intact periosteum. Bones may have single or multiple fissure lines of any configuration: transverse, oblique, spiral, longitudinal, or radiating from a central point. Since fissure fractures occur only in a single cortex and represent an incomplete fracture, the fractured bone should maintain its normal shape.

Complete Fractures Complete fractures are indicated by the complete loss of bony continuity, allowing overriding and deformation. Complete fractures are far more common than incomplete fractures. They may be classified further by the shape of the fracture line. The following system describes complete fractures. Transverse fracture Tranverse fracture implies a fracture line that is transverse to the long axis of the bone. Transverse fractures may be relatively smooth or may be rough or have deep teeth on the fractured surfaces. Most are caused by bending forces. Roughness simplifies anatomical alignment and increases the likelihood of rotational stability once reduced. Once these fracture fragments have been reduced, fragment override should not occur Oblique fracture Oblique fracture implies a fracture line that is oblique to the long axis of the bone. The two cortices of each fragment are in the same plane without spiraling. The edges of an oblique fracture may be rough but are usually smooth. The cortical edges are flat, rather than sharp. These fractures generally result from bending, with superimposed axial compression. As a result of the obliquity of the fracture line, this fracture tends to override or rotate unless traction is maintained throughout the period of healing Spiral fracture Spiral fracture indicates a fracture line that spirals along the long axis of the bone; it is caused by torsional twisting or rotational forces. Spiral fractures tend to have extremely sharp points and edges, which frequently accompany soft tissue trauma or an open fracture. Reduction of spiral fractures is difficult without constant traction or internal fixation, since these fractures tend to override and rotate into deformity Comminuted fracture Comminuted fracture implies at least three fracture fragments, the fracture lines of which interconnect. The individual fracture lines that form the comminuted fracture may be transverse, oblique, or spiral. Comminuted fractures are generally caused by high-energy trauma, as typified by automobile accidents, fall from hight etc. Comminuted fractures are difficult to reduce and fix because they have no inherent stability. Constant external traction and alignment or internal fixation is required. Multiple fracture Multiple fracture implies three or more fracture fragments in a single bone; however, unlike comminuted fractures, the fracture lines do not interconnect. The individual fracture lines may be of any shape. Typically this term describes two completely independent fractures affecting the same bone, such as an oblique fracture of the proximal femur and an epiphyseal fracture of the distal femur. Neither of these fractures interconnects. Reduction and EMSA Macedonia Summer School 2013

Course Book EMSS04 fixation of a multiple fracture requires two separate reductions and fixations

Closed Fracture A closed fracture implies a fracture that remains encased within the skin and musculature that surround it. No wound or mucosal membrane overlies the fracture. The fracture does not communicate with the outside environment. A synonym found in older literature is “simple fracture”

Open Fracture Unlike a closed fracture, the open fracture communicates with the outside environment. This may occur through a large wound in the soft tissue and skin or through a tiny puncture wound. Regardless of wound size, any fracture that has communicated with the outside is considered an open fracture. Of greatest significance is the potential for contamination of the fracture itself.A synonym found in older literature is “compound fracture.” Clinical Signs And Symptoms In most instances the clinical signs associated with fracture make diagnosis uncomplicated. Pain Pain over the site of fracture is common. In incomplete fractures this may be the only clinical indication. Direct tenderness can be misleading, since it may be due to a contusion or other soft issue damage caused by a blow. Indirect tenderness is a more accurate sign of fracture. It is produced by pressure in the long axis of the bone exerted at its two extremities. If there is a break in the continuity of the shaft, such pressure will cause pain at the fracture site that is quite distinct from the pain of injured soft tissue parts. Local trauma Examination of the area around a fracture may demonstrate swelling, hematoma, contusion, or laceration if the fracture is open. Often because of extreme swelling, the examiner will be unable to palpate crepitation. Local swelling, although present in many other conditions, is one of the most constant signs of a fracture. Immediately after injury the swelling may be sharply outlined as a result of bleeding from the bone and the soft parts. An indistinctly outlined swelling that occurs later is caused by edematous infiltration. Generally the swelling increases for 24 to 48 hours, then gradually subsides (particularly under treatment). When applying bandages and splints immediately following fracture, it is important to bear in mind that swelling will subside. Abnormal posture or limb positioning Abnormalities of positioning, when of acute onset associated with trauma, usually reflect a fracture. Deformity, a deviation from the normal anatomical structure, may be caused by displacement of the bony framework as in a fracture or dislocation, but it may also be caused by changes in configuration due to a neoplasm. The displacement of bone fragments that produces deformity in a fracture may be angular, longitudinal, or rotational. Longitudinal displacements may cause shortening, referred to as overriding, or may result in separation of the fragments, termed distraction (e.g., fractures of the olecranon). In most cases the primary displacement is determined by the direction and force of an injury and is

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EMSA Macedonia maintained and often increased by the contraction of muscles. If in doubt about positioning, comparison with the opposite limb or side of the body part is advised. Crepitus Crepitus is a sign of fracture that is considered pathognomonic. Bony crepitus is the gritting sensation transmitted to the palpating fingers by the contact of the broken bone ends on each other. There are other forms of crepitus (pseudocrepitus) such as occurs in some cases of arthritis, partial luxations of the patella, or luxations of the coxofemoral joint. The absence of crepitus does not necessarily indicate the absence of a fracture. The interposition of a piece of soft tissue between the fragments will prevent crepitus. It is also absent when the ends of the bones are so far apart that they cannot be brought into contact, or when they are impacted. Crepitation should be elicited with the utmost precaution because of the danger of causing further damage to bony fragments and surrounding soft tissue. Vigorous palpation, which may turn a routine closed fracture into a contaminated open one should be avoided. Abnormal mobility A false point of motion is also pathognomonic. It occurs if there is a complete fracture of the shaft of a long bone; it does not occur in an incomplete or impacted fracture. Mobility near a joint may be difficult to differentiate from normal or abnormal mobility of the joint itself. In order to avoid additional trauma, the same precaution should be taken in eliciting this symptom as in eliciting crepitus. Radiographic signs Fracture, either diagnosed or suspected, should be documented by radiography. At least two views including the joints above and below the fracture are needed. Fracture of joints or special anatomical locations may require additional radiographs or special positioning. Radiographs should be read on a well-illuminated flat surface. If questions about anatomical structures exist, the opposite limb or side of the body may be radiographed for comparison. The specific radiographic signs of fracture include those listed below: A break in the continuity of a bone A line of radiolucency when the fragments are distracted A line of radiopacity when the fragments are compressed or superimposed

Principles Of Fracture Treatment The ideal objective of fracture treatment is to provide a completely rehabilitated patient as quickly as possible. Successful fracture treatment comprises a perfectly aligned bone of full length that has solidly united joints that are freely movable to their fullest range, and musculature, innervation, and integument surrounding the site of the previous fracture that are completely normal. This idealized concept can rarely be achieved in a clinical situation. It is important that the surgeon strive to meet these criteria using all avenues of treatment by means of operative and nonoperative management of the fracture.The objectives to be strived for include the following: 1.Sufficient reconstruction or restoration of normal form to meet the requirements expected of the limb 2. Immobilization of bone fragments until fracture healing has occurred 3. Mobilization of all joints involved during the process of fracture healing to prevent joint stiffness, fracture disease, and muscle atrophy. (The recent literature tends to substantiate the value of early passive motion before active motion can begin. EMSA Macedonia Summer School 2013

Course Book EMSS04 4. Rehabilitation of the patient within a reasonable time

Methods Of Management In general, there are two types of management: non-operative (conservative) and operative. Fracture management can be classified according to the type of method used to achieve bony union. This classification is given below: Closed reduction with immobilization- such as a cast or splint External fixation- External skeletal fixation in which reduction may be either open or closed and immobilization of the bone is maintained through the use of pins, clamps, and sidebars Closed reduction and internal fixation -rather than making the exposure in the fracture site, an incision is made through the skin allowing introduction of the internal fixation device, for example intramedullary nailing. Open reduction with internal fixation- exposure to the fracture site, reduction under direct visual control and fixation with different types of implants such as intramedullary pins or plate and screws. The treatment of specific fractures, the techniques for non-operative and operative treatment and their complications are beyond the scope of this review.

Injuries To The Joint A joint dislocation, or luxation, occurs when there is an abnormal separation in the joint, where two or more bones meet. A partial dislocation is referred to as a subluxation. Dislocations are often caused by sudden trauma on the joint like an impact or fall. A joint dislocation can cause damage to the surrounding ligaments, tendons, muscles, and nerves.[ Dislocations can occur in any joint major (Shoulder, knees, etc.) or minor (toes, fingers, etc.). The most common joint dislocation is a shoulder dislocation. Joint dislocations are caused by trauma to the joint or when an individual falls on a specific joint. Great and sudden force applied, by either a blow or fall, to the joint can cause the bones in the joint to be displaced or dislocated from normal position. With each dislocation, the ligaments keeping the bones fixed in the correct position can be damaged or loosened, making it easier for the joint to be dislocated in the future. Some individuals are prone to dislocations due to congenital conditions, such as hypermobility syndrome. Hypermobility syndrome is genetically inherited disorder that is thought to affect the encoding of the connective tissue protein’s collagen in the ligament of joints. The loosened or stretched ligaments in the joint provide little stability and allow for the joint to be easily dislocated. The following symptoms are common with any type of dislocation:intense pain, joint instability, deformity of the joint area, reduced muscle strength, bruising or redness, immobility of joint. A dislocated joint usually can only be successfully ‘reduced’ into its normal position by a trained medical professional. Trying to reduce a joint without any training could result in making the injury substantially worse. X-rays are usually taken to confirm a diagnosis and detect any fractures which may also

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EMSA Macedonia have occurred at the time of dislocation. A dislocation is easily seen on an X-ray. Once a diagnosis is confirmed, the joint is usually manipulated back into position. This can be a very painful process, therefore this is typically done either in the emergency department under sedation or in an operating room under a general anaesthetic. It is important the joint is reduced as soon as possible, as in the state of dislocation, the blood supply to the joint (or distal anatomy) may be compromised. This is especially true in the case of a dislocated ankle, due to the anatomy of the blood supply to the foot. Some joints are more at risk of becoming dislocated again after an initial injury. This is due to the weakening of the muscles and ligaments which hold the joint in place. The shoulder is a prime example of this. Any shoulder dislocation should be followed up with thorough physiotherapy. After a dislocation, injured joints are usually held in place by a splint (for straight joints like fingers and toes) or a bandage (for complex joints like shoulders). Additionally, the joint muscles, tendons and ligaments must also be strengthened. This is usually done through a course of physiotherapy, which will also help reduce the chances of repeated dislocations of the same joint. A sprain is an injury in a joint, caused by the ligament being stretched beyond its own capacity. A muscular tear caused in the same manner is referred to as a strain. In cases where either ligament or muscle tissue is torn, immobilization and surgical repair may be necessary. Ligaments are tough, fibrous tissues that connect bones to other bones. Sprains can occur in any joint but are most common in the ankle and wrist. Symtomes of sprained joint are: pain, swelling, bruising, decreased motility and function of the affected joint. The sprains are classified in three degrees by the severity of the soft tissue injury: First degree sprain - is a tear of only a few fibers of the ligament. Second degree sprain - is a tear of part of a ligament, from a third to almost all its fibers. Third degree sprain - is a complete tear of the ligaments The diagnosis of a sprain injury is made by a physical examination. In most cases an x-ray (or stress x-ray) of the affected joint is obtained to ensure that there are no fractures. If a tear in the ligament is suspected, then an MRI or arthroscopy is obtained. MRI is usually ordered after swelling has subsided and can readily identify the presence of a ligament inju Sprains typically occur when the joint is overextended. This can cause over stretching of the joints, tear or slipping of the ligament. Although any joint can experience a sprain, some of the more common include: The ankle. It is the most common, and has been said that sprains such as serious ankle sprains are more painful and take longer to heal than actually breaking the bones in that area.[4] See sprained ankle for more details. The knee. Perhaps one of the more talked about sprains is that to the anterior cruciate ligament (ACL) of the knee. This is a disabling sprain common to athletes. The fingers. The wrist. The toes. EMSA Macedonia Summer School 2013

Course Book EMSS04 There are certain factors which increase risk of sprains. Fatigue of muscles generally leads to sprains. When one suddenly starts to exercise after a sedentary lifestyle, sprains are quite common. While scientific studies are lacking, it is often thought that not warming-up is a common cause of sprains in athletes. Warming-up is thought to loosen the joint, increases blood flow and makes the joint more flexible. Diagnosis of sprains is not difficult but in most cases X-rays are obtained to ensure that there is no fracture. In many cases, if the injury is prolonged, magnetic resonance imaging (MRI) is performed to look at surrounding soft tissues and the ligament. The first modality for a sprain can be remembered using the acronym RICE. The treatment of sprains depends on the extent of injury and the joint involved. Medications like nonsteroidal anti-inflammatory drugs can relieve pain. Weight bearing should be gradual and advanced as tolerated. Rest: The sprain should be rested. No additional force should be applied on site of the sprain. In case of, for example, a sprained ankle, walking should be kept to a minimum. Ice: Ice should be applied immediately to the sprain to reduce swelling and pain. It can be applied for 10â&#x20AC;&#x201C;15 minutes at a time (longer application of ice may cause damage instead of healing), 3-4 times a day. Ice can be combined with a wrapping to minimize swelling and provide support. Compression: Dressings, bandages, or ace-wraps should be used to immobilize the sprain and provide support. When wrapping the injury, more pressure should be applied at the far end of the injury and decrease in the direction of the heart; the reason for this is that it more easily causes unnecessary fluid to be flushed back up the blood stream in order to be recycled. Compression should not cut off the circulation of the limb. Elevation: Keeping the sprained joint elevated (in relation to the rest of the body) will also help minimize swelling. Ice and compression (cold compression therapy) will not completely stop swelling and pain, but will help to minimize them as the sprain begins to heal itself. Careful management of swelling is critical to the healing process as additional fluid may pool in the sprained area. The joint should be exercised again fairly soon, in milder cases from 1 to 3 days after injury. Special exercises are sometimes needed in order to regain strength and help reduce the risk of ongoing problems. The joint may need to be supported by taping or bracing, helping protect it from re-injury. Prolonged immobilization delays the healing of a sprain, as it usually leads to muscle atrophy and stiff joint. The components of an effective rehabilitation for all sprain injuries include increasing range of motion and progressive muscle strengthening exercise. These should be taken care of without delay

Splinting Splint is a device used to stabilize a fracture or dislocation. It is used in pre-hospital and hospital care as a temporary or definitive treatment of acute injuries of the musculo-skeletal system. The splints are used to prevent movement of the injured part of the body. By that, the pain and the inflammatory response to injury is reduced.Further damage is reduced by reducing the movement of the injured part of the body as well as bleeding and swelling.

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EMSA Macedonia General Principles of Splinting When injury is suspected, the site of the injury must be exposed (remove clothes, shoes etc). The physical exam must be detailed, even though the injuries are straightforward. One must examine the neuro-vascular status of the affected site(ex.limb distal to the site of injury) before and after splinting. All wounds must be irrigated with sterile saline and covered with sterile dressing. Do not try to explore the wounds in emergency settings because it can cause further damage, promote bleeding and spread infection. It is recommended not to move the patient prior splinting unless you or the patient are in immediate hazard. There are few general rules that are applied in the splinting technique. The joints above and below the fracture site are immobilized as well as the bones above and below the injured joint. All rigid splints must be padded; the bony prominences need extra padding. One should maintain manual immobilization while splinting. Gentle longitudinal traction is used to align deformed limbs. If the deformity is severe the splint should be applied with no attempt to reduce the deformity. Exception comes when the affected extremity is pulseless or cyanotic. All patients with suspected spinal injury must be immobilized on a backboard; all suspected cervical spine injuries are immobilized with rigid collar. Not immobilizing these injuries can cause devastating damage to the patient; thatâ&#x20AC;&#x2122;s why they must be applied if a slight suspicion exists, and removed after clearing the injuries ( by radiography, CT). The golden rule is: When in doubt SPLINT. There are multiple types of splints used in pre-hospital and hospital care. Improvised splints are used when no medical care is available. Different materials can be used: newspapers, cardboard, wood, plastic etc. Standard and precontured splints are available for different types of injuries. In general there are three types of spins by the type of fixation: rigid fixation (wire splint, quick splint,board,etc), soft fixation (air splints),traction splints (Thomas Half-Ring).

EMSA Macedonia Summer School 2013

Course Book EMSS04

The Approach To The ED Patient

Examination Of Patients With An Acute Abdominal Pain by D-r. Nikola Brzanov Medical Faculty - Skopje

Initial Assessment General Impression ● Mechanism of injury or nature of illness ● Find and treat life threatening conditions ● Problems with Airway, Breathing, or Circulation Mental Status ● If the patient appears to be unconscious, check for responsiveness ● Evaluate mental status using AVPU ● Obtain a chief complaint, if possible Airway ● Do you hear any noise? ● Will the airway stay open on its own? ● Open the airway - head-tilt-chin-lift or jaw thrust – as needed ● Clear the airway – as needed ● Suction - as needed ● Insert an OPA/NPA - as needed Breathing ● Do you see any signs of inadequate respirations? ● Is the rate and quality of breathing adequate to sustain life? ● Is the patient complaining of difficulty breathing? ● Quickly palpate the chest for unstable segments, crepitation and equal expansion of the chest ● If the patient is responsive and breathing < 8 or > 24, administer oxygen mask ● If the patient is unresponsive and breathing is adequate, administer oxygen mask ● If the patient is unresponsive and breathing is inadequate, administer oxygen using AMBU Bag

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EMSA Macedonia Circulation ● If the patient is unresponsive, assess for presence and quality of the carotid pulse. ● If the patient is responsive, assess the rate and quality of the radial pulse. ● If radial pulse is weak or absent, compare it to the carotid pulse. ● For patients 1 year old or less, assess the brachial pulse. ● Is there life threatening hemorrhage? ● Assess the patient’s perfusion by evaluating skin for color, temperature and condition ● Cover with blanket and elevate the legs as needed for shock (hypoperfusion) Identify Priority ● If the patient is CRITICAL, UNSTABLE or POTENTIALLY UNSTABLE perform the rapid trauma assessment ● If the patient is or STABLE, perform the appropriate focused trauma exam Rapid Trauma Assessment Inspect and palpate the body for injuries (Head-to-Toe Assessment) ● HEAD - inspect and palpate for signs of injury, DCAP-BTLS, blood & fluids from the head ● NECK - inspect and palpate for signs of injury, DCAP-BTLS, jugular vein distention, crepitation, apply cervical spinal immobilization collar - if not already done ● CHEST - inspect and palpate for signs of injury, DCAP-BTLS, paradoxical movement, crepitation ● ABDOMEN - inspect and palpate for signs of injury, DCAP-BTLS, pain, firm, soft, distended ● PELVIS - inspect and palpate for signs of injury, DCAP-BTLS, if no pain is noted, gently compress the pelvis to determine tenderness or unstable movement. ● EXTREMITIES - inspect and palpate the lower and upper extremities for signs of injury, DCAP-BTLS, crepitation, distal pulses, sensory function, motor function ● POSTERIOR - Log roll the patient. Maintain c-spine stabilization, inspect and palpate for injuries or signs of injury, DCAP-BTLS Focused Trauma Assessment - Perform On Stabile Patients with No Significant MOI ● Follow order of the Rapid Assessment ● Focus assessment on the specific area of injury or complaint

Obtain Baseline Vital Signs Respirations Rate: Watch the chest/abdomen and count for no less than 30 seconds. If abnormal respirations are present count for a full 60 seconds. Quality: Normal, deep, shallow, any unusual pattern?, labored?, noisy breathing? Pulse Rate: Check the radial pulse. If pulse is regular, count for 30 seconds and multiply x 2. If it is irregular, count for a full 60 seconds. Quality: Regular, irregular, strong, weak EMSA Macedonia Summer School 2013

Course Book EMSS04 Skin Color : Normal, cyanotic, pale, flushed, jaundice Temperature - touch the skin: Warm, hot, cool, cold Blood Pressure Blood pressure should be measured in all patients over the age of 3. Auscultate the blood pressure. In a high noise environment, palpate (only the systolic reading can be obtained). Pupils - use a penlight to check reactivity of the pupils; also assess for size.

Physical Examination of Patients with Acute Abdominal Pain Traumatic – Blunt or penetrating injuries. Non – Traumatic Abdomen divided into four quadrants by body mid-line, horizontal plane through umbilicus. ● Right Upper Quadrant Liver - Gall bladder, duodenum, pancreas, colon ● Left Upper Quadrant - Stomach, Spleen, left lobe of Liver, body of Pancreas, left kidney, colon, parts of transverse and descending colon ● Right Lower Quadrant - Cecum, appendix, right ovary and fallopian tube, right ureter ● Left Lower Quadrant - Part of descending colon, sigmoid colon, left ovary and fallopian tube

Common abdominal acute diseases by quadrants

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EMSA Macedonia Components of the Abdominal Exam a. Inspection ● Inspection is visual review of the abdomen. It involves assessing both the symmetry and contour of the abdomen. Contour describes the overall shape of the abdomen while symmetry is used to assess specific areas of imbalance. ● Inspection also includes: 1. checking for bruises, discolorations or straie 2. assessing the umbilicus – is it inflamed, clean? 3. assessing skin turgor - is the patient dehydrated? 4. looking for movement associated with peristalsis b. Auscultation ● Primary purpose is to listen for bowel sounds. Also is used to assess vascular sounds ● Procedure: 1. Perform prior to palpation and percussion. 2. Use the diaphragm of the stethoscope. 3. Place lightly against the skin. 4. Begin in the RLQ at the ileocecal valve area ● What are bowel sounds? Bowel sounds originate from the movement of air and fluid through the small intestine. Bowel sounds are high pitched, gurgling or scratching sounds that occur approximately every 5 to 15 seconds. They can be heard in all four quadrants. ● Hyperactive bowel sounds are loud, high-pitched, rushing and tinkling sounds (borborygmi). Absent bowel sounds are defined as lack sounds after 5 minutes of auscultation. ● Bowel Obstruction ● Symptoms: pain, nausea, vomiting, hyperactive peristalsis, constipation, occasional diarrhea. c. Percussion ● Serves two purposes: 1. To detect gaseous distention and/or fluid within the abdomen. 2. To assess the size and position of solid organs within the abdomen. ● Tympany and dullness are sounds heard through percussion. 1. Tympany represents air and fluid and usually predominates due to the presence of air in the colon and small bowel. 2. Dullness indicates solid masses d. Palpation ● Used to substantiate findings noted from previous measures of assessment and to further explore the abdomen. Palpation permits evaluation of the major abdominal organs in terms of shape, size, position and tenderness. ● Light palpation is a gentle exploration using both hands. Useful to detect overall abdominal tenderness. ● Deep palpation is used to detect masses and to assess abdominal organs. EMSA Macedonia 73 Summer School 2013

Course Book EMSS04 Special abdominal examination techniques ● Carnett’s sign ● McBurney point ● Cough test ● Closed eyes sign ● Murphy’s sign ● The psoas sign ● The obturator sign ● The Rovsing sign ● Rebound tenderness ● CVA tenderness Diagnostic Testing Imaging studies and laboratory tests.

An acute surgical abdomen is when a good surgeon says it is an acute surgical abdomen.

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Available Only In Digital Form Copyright ÂŠ EMSA Macedonia Course Book Emergency Medicine Summer School 2013