The Course Book EMSS 01 by Borislav Manev

Acta, Non Verba!

European Medical Students’ Association - Macedonia 1st Summer School on Emergency Medicine

The 1st International Summer School on Emergency Medicine in Macedonia 27.06-01.07.2010 Ohrid, Macedonia Hotel Klimetica

Organized by: The European Medical Students’ Association EMSA – Macedonia Official language: English President of EMSA – Macedonia: Borislav Manev

Under the auspices of: Dean of the Medical Faculty – Skopje Prof.D-r. Nikola Jankulovski Vice-Dean for Education Prof.D-r. Sonja Alabakovska Vice-Dean for International Collaboration Prof. D-r. Daniela Miladinova

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Students’ Association - Macedonia 1st Summer School on Emergency Medicine

President of the Scientific Board: Prof. D-r. Daniela Miladinova

The Scientific Board:



Goran Kondov M.D. /Professor of Thoracic surgery / Head of Surgery Department / Medical faculty Skopje / University Ss. Cyril and Methodius /



Sashko Kedev M.D. /Professor of Cardiology / Medical faculty Skopje / University Ss. Cyril and Methodius /



Ilija Pangovski M.D. / Professor of Neurosurgery / Medical faculty Skopje / University Ss. Cyril and Methodius /



Daniela Caparovska M.D. / Professor of Internal Medicine / Head of Toxicology Department / Medical faculty Skopje / University Ss. Cyril and Methodius /



Talevska M.D. / Professor of Anesthesiology/ Medical faculty Skopje / University Ss. Cyril and Methodius /



Andreja Arsovski M.D. / Spec. General Thoracic Surgery / Medical Director of the first private general hospital Re-Medika /



Gjorgji Babushku M.D. / Spec. Gynecology and Obstetrics / Subspecialist in Gynecological Surgical Oncology

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Studentsâ&#x20AC;&#x2122; Association - Macedonia 1st Summer School on Emergency Medicine

Organizing Committee:

Mladenovska Sanja Pangovska Radmila Stankovik Vera Gjorgjevski Marko Milev Tihomir Todorovska Anastasija Dejanovik Momir Stojkovska Frosina Bundovska Marija Kuzmanovska Biljana Manuela Maneva Vitlarov Nikola Gjorgova Sandra Cvetanka Atanasovska Jetmir Sadiku

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Students’ Association - Macedonia 1st Summer School on Emergency Medicine

Supporters: Medical Faculty – Skopje Student Parliament of the Medical Faculty European Medical Students Association

General Sponsors: A.D. Alkaloid – Skopje Remedika – First general private hopsital

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Studentsâ&#x20AC;&#x2122; Association - Macedonia 1st Summer School on Emergency Medicine Other Sponsors and Supporters: PHO Prim. Dr. SamardĹžiski â&#x20AC;&#x201C; Stip Private health institution in General and Internal Medicine; DIAGNOSIS prevention and treatment of diseases Str. Partizanska bb 2000 Stip Phone 032/395-143 faks: 032/394-143 www.nvz.com e-mail: pzusamardziski@gmail.com

Small polyclinic center with great opportunities Here in our office are not only talking about humanity, but it is implemented as well and accepts responsibility. We had and have the energy to create solutions and to fulfill the tasks. Our health care institution provides you with comprehensive medical services in one day, which according to the patient may be in the office or at home. In this institution with the reputation and trust among patients, we have provided pharmacies, laboratory and ultrasonic diagnosis and professional quality, fast and economical service in all areas.

Introduction

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Students’ Association - Macedonia 1st Summer School on Emergency Medicine st

Dear participants to the 1 SSEM, This is a project that brings together students from different medical schools from Europe around the world interested in gaining and exchanging knowledge in the field of emergency medicine. The main theme of the project is emergency medicine and it consists of the following topics: • • • • • •

Cardiopulmonary resuscitation Shock & coma Drug abuse & poisoning Emergency surgery Emergency care in gynecology Principles of critical medical thinking

The scientific part is composed of lectures, interactive seminars, practical skills and daily cases held by our leading experts in this field. Every student will have a chance to renew and expand his/her knowledge, as well as master new skills. Alongside the scientific part, a well organized social program is meant to enrich this unique experience by enabling participants to make new friendships and to develop a feeling of team spirit. The social program includes sightseeing and an insight in Ohrid's rich history, sport activities, medical games and nightlife... The school is concluded on July 1st by a written exam and a certificate of attendance which is handed to each participant on a ceremonial gala dinner. Evaluation of the School is made through a questionnaire which grades all the segments (boarding and lodging, lectures, seminars, workshops, cultural and social life, lecturers and the organizing committee). I hope that this meeting will expand the knowledge and enrich the experience of the participants in the field of emergency medicine. Dear students, I wish you all successful work and pleasant stay in Ohrid.

President of the scientific board, Prof. D-r. D. Miladinova

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Students’ Association - Macedonia 1st Summer School on Emergency Medicine

Day One 27.06

Till 15.00

Day Two 28.06 08.00 - 09.30 Breakfast 10.00 – 11.00 Urgent Surgery Prof.Kondov

Day Tree 29.06 08.00 - 09.30 Breakfast 10.00 – 10.30 Workshop Investigating Cardiologycal Case

Day Four 30.06 08.00 - 09.30 Breakfast 10.00 – 10.30 Workshop Investigating A Neurological Case

(Coffee Break)

11.30 -12.30 Urgent Surgery Prof. Arsovski

11.00 - 12.30 Cardiology Seminar; Lessons; Prof. Kedev

11.00 – 12.30 Coma And Neurologi Seminar; Lessons; Prof. Pangovski

13.00 – 14.30 Lunch 15.00 – 16.00 Urgent Care Gynecology Prof.Babusku

13.00 – 14.30 Lunch 15.00 – 17.00 Poisoning, Allergies Anaphylaxis Prof. Caparovska 17.30-19.00 Beach Games

13.00 – 14.30 Lunch 15.00 – 18.00 CPR Anthropomorphic Phantoms

Room Checking Accommodation

Day Five 01.07 08.00 - 09.30 Breakfast

10.00 – 12.30 Evaluation

Registration

15.00 - 18.00 Sightseeing Ohrid (With Professional Guide)

18.00 – 19.00 Introducing Participants ( IceBreaking Games )

16.30 – 18.30 Surgical Suturing And Politraumatic Patient

20.00 – 21.00 Opening Ceremony And Formal Welcoming 21.00 … Cocktail Party

19.30 – 21.30 Dinner

19.30 – 21.30 Dinner At The Beach

19.30 – 21.30 Dinner

22.00 … Night In Town And Disco And Clubbing

22.00 … Beach Party With Live Dj Set

Formal Closing Certificates

12.30 – 16.30 Boat Tour And Visiting St. Naum Lunch

18.30 – 19.30 Test

Life Music Party At Hotels Balcony

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

Goodbye And See You Next Summer…

European Medical Students’ Association - Macedonia 1st Summer School on Emergency Medicine

Contents

Coma...............................................................................................................12 Craniocerebral hematomas.............................................................................17 Cardiopulmonary resuscitation.......................................................................25 Urgent Procedures in thoracic surgery............................................................31 Pneumotorax...................................................................................................42 Emergency Gynecology...................................................................................52 Drug Poisoning................................................................................................56 Acute Coronary Syndrome..............................................................................59 Skills and Knowledge on Overdose Prevention (SKOOP) ...............................64

Workshop……………………………………………………………………………….…………………….64

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Studentsâ&#x20AC;&#x2122; Association - Macedonia 1st Summer School on Emergency Medicine

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Studentsâ&#x20AC;&#x2122; Association - Macedonia 1st Summer School on Emergency Medicine

The Lecturesâ&#x20AC;Ś

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Studentsâ&#x20AC;&#x2122; Association - Macedonia 1st Summer School on Emergency Medicine COMA â&#x20AC;&#x201C; COUNSCIOSNESS DISORDER Introduction

The huge increase in traffic traumatism leads to greater degree of injury of the entire organism in the system of polytraumatized patients which enormously increases their morbidity and mortality. This is worse in patients with severe craniocerebral injuries and therefore imposes the goal of rapidly detecting the compressive intracranial lesions, their surgical treatment with decompression and undertaking a variety of therapeutic measures implemented in these critical patients. The evaluation of the WHO mortality injured in traffic could shrink by 20% if taken timely appropriate emergency assistance, as well as monitoring of the disabled people from the moment of injury to admission to hospital. Most of the brain injuries are manifested by disturbances of consciousness, which requires continuous monitoring of the injured patients and an accurate determination of the state of consciousness as essentially a "contract" between doctors of different levels of provision of assistance. The term coma evolved from its Greek meaning "sleep" to the modern definition that patients in a coma do not give a verbal response, do not perform commands and do not open their eyes spontaneously.

Consciousness and its disorders Consciousness is a condition of having an awareness of one's environment and one's own existence, sensations, and thoughts, on the other hand coma is a condition of a complete loss of self-awareness. The Psychological definition describes the consciousness as an auto psychological orientation and recognition of people as an alopsychological orientation. This also includes the orientation in time and space, which in the coma condition is totally lost.

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Students’ Association - Macedonia 1st Summer School on Emergency Medicine There are two aspects of the consciousness: the content of consciousness and wakefulness. While the first one is usually disturbed from injuries in the brain hemispheres, the second one depends from the brainstem structure. The content of consciousness is a sum of cognitive and affective matters of mental functions. Any kind of lesion that affects the complete cognitive function also decreases the consciousness and the patient will have a decreased self-awareness and cannot be treated as a completely conscious person. A conscious disorder is a condition of a decreased awareness, in which there is a change between irritability and drowsiness. Somnolence is a condition of increased sleepiness where the patient wakes up from sleep, shows adequate reactions, but after the stimulation ends he falls asleep again. Sopor is a condition where patient have difficulties with waking up and are unaware of the external surroundings. When a stimulus is implicated they respond with spontaneous moves, but after that again they go back in deep sleep. Coma is a condition where the patient can’t establish a verbal contact and can’t open his eyes even when a hard stimulus is implicated.

Types of Coma According to the motor responses there are 4 types of coma: -

Coma with adequate reactions

Coma with inadequate reactions ( evoked)

Coma with decerebration twists

Non reflexive coma

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Students’ Association - Macedonia 1st Summer School on Emergency Medicine Vegetative coma is a consciousness disorder that occurs as a result of a gross impairment of the brain: there is consciousness with absence of cognitive functions, and there is a sleep-waking cycle. The patient is immobile, with normal breathing and blood pressure, and doesn’t give any verbal response or understand words. This condition can persist in years. The fundamental alterations are in the cerebral hemispheres: cortical laminar necrosis, particularly in the occipital region and the hippocampus. Akinetic mutism is a condition where the patient is immobile with tendency for awakening and presence of the sleep-waking cycle. The patient doesn’t show any motor, verbal or emotional responses, except for the eyeball movements. Apallic syndrome (comma vigil) is a heavier condition where the patient’s eyes are open, but they’re not able to follow movements. Fixed or blocked condition is a condition in which a patient is aware and awake but cannot move or communicate due to complete paralysis of nearly all voluntary muscles in the body except for the eyes. Only moves are vertical eye movement and blinking, which are used as a mean for communication. The patient is conscious with an auto – and alo- orientation. In most cases there is a large infarction in the base of the pons or a tumor, large hemorrhage in the pons, central pontine myelinolysis or a head injury.

Examination of a comatose patient At the beginning of the examination is inspection for injury and vital signs. When there aren’t any other information for the reason why is the patient in a coma, it’s often that the reason is drug abuse, apoplexy, epilepsy or head injury.

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Students’ Association - Macedonia 1st Summer School on Emergency Medicine Monitoring: Signs of lateralization: - Left or right cheek inflate while breathing, (paresis) - The patient lies on his back; the foot from the paralyzed side is laterally rotated - When you lift the patient’s hand or leg (about 45 degrees) and then let it go, the paralyzed limb will fall faster and more languorously than the good one.

Glasgow coma scale The degree of unconsciousness can be measured with the Glasgow coma scale. It’s the most commonly used complex scale, using three groups of observation. This looks at eye activity, verbal and motor responses, and assigns points for each to give a composite score. ACTIVITY

SCORE

Eye Opening None

1 = Even to supra-orbital pressure

To pain

2 = Pain from sternum/limb/supra-orbital pressure

To speech

3 = Non-specific response, not necessarily to command

Spontaneous

4 = Eyes open, not necessarily aware

Motor Response None

1 = To any pain; limbs remain flaccid

Extension

2 = Shoulder adducted and shoulder and forearm

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Studentsâ&#x20AC;&#x2122; Association - Macedonia 1st Summer School on Emergency Medicine internally rotated Flexor response

3 = Withdrawal response or assumption of hemiplegic posture

Withdrawal

4 = Arm withdraws to pain, shoulder abducts

Localizes pain

5 = Arm attempts to remove supra-orbital/chest pressure

Obeys commands

6 = Follows simple commands

Verbal Response None

1 = No verbalization of any type

Incomprehensible

2 = Moans/groans, no speech

Inappropriate

3 = Intelligible, no sustained sentences

Confused

4 = Converses but confused, disoriented

Oriented

5 = Converses and oriented TOTAL (3â&#x20AC;&#x201C;15):

The smallest index is 3 (the patient does not open his eyes, give verbal response or do an extension) and the largest is 15 (spontaneous look, oriented and commit orders).

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Students’ Association - Macedonia 1st Summer School on Emergency Medicine

CRANIOCEREBRAL HEMATOMAS

These appear as the result of a direct or indirect force impacting the skull, and the degree of the damage depends on the intensity of that force. The examination should encompass: time, place and mechanism of injury, patient condition, evolution of the condition since the initial trauma, first medical aid applied. It is very important to create and maintain a verbal contact with the patient, and conduct a general examination (appearance, pulls, tension, breathing, consciousness, pupils) and a neurological exam. A list with the abovementioned parameters is created, and the same is updated every 2 hours since the injury. An increase in the medial arterial pressure, bradicardia, tachycardia, neurological symptoms and a unilateral dilatation of the pupil are always clinical signs towards increased intracranial pressure and a compressive intracranial hematoma. Diagnosis: 

Clinical Examination



Craniogram, 2 ways



EEG



Ultrasound



Cerebral angiography

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Students’ Association - Macedonia 1st Summer School on Emergency Medicine 

Transcranial dopler



MRI

Classification of Craniocerebral trauma 1. Localization 2. Damage degree 3. Clinical development 1. Concerning the localization of the injury: - In relation with the head and brain region - Injury of the different layers of the head – epicranium, brain 2. Concerning the damage degree: - skin and epicranium: contusion, lacerations, stab wounds, gunshot wound etc.. - cranium: fractures (linear, impressive, comminutive) - injury of the meningea - injury of blood vessels and venous sinuses - brain injury (laceration, contusion) 3. Concerning the clinical development: - Cerebral Commotion

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Studentsâ&#x20AC;&#x2122; Association - Macedonia 1st Summer School on Emergency Medicine - Cerebral Contusion, - Without brain stem incarceration signs, - With brain stem incarceration signs (decerebration), - Brain compression from: - bone fragments, - epidural or subdural hematoma, - intracerebral hematoma. The craniocerebral injuries can be: Open and Closed Closed CCI are those injuries in which the integrity of the skin is not interrupted, with or without fractures of the base of the cranium. This includes: - head contusion - cerebral commotion, - cerebral contusion - Intracerebral compressive syndrome, with epidural, subdural or intracerebral hematoma

Open CCI are injuries with damage of the soft tissues of the head, with a wound, and with or without fractures of the cranium or its base. - Open non-penetrating CCI, the dura mater or arachnoidea is not damaged - Open penetrating CCI, the meningeas are injured

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Students’ Association - Macedonia 1st Summer School on Emergency Medicine - Open perforating CCI, with a foreign body present inside the brain Skull Fractures

These may be: - Linear, - Communitive (multifragmented) - Impressive fractures

An impressive skull fracture Fractures of the base of the skull

-Fossa crania anterior – nasoliquorea – brullen hematoma (glasses-like) -Fossa crania media – otorrhagia, otoliquorea -Fossa crania posterior – Batle’s sign (mastoid hematoma)

Cerebral commotion

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Studentsâ&#x20AC;&#x2122; Association - Macedonia 1st Summer School on Emergency Medicine This is only a functional damage to the brain. Clinically, the main sign is a short loss of consciousness, immediately after the trauma. Another sign is amnesia, which is usually retrograde. The treatment is conservative (observation) Cerebral Concussion This is an organic injury to the brain, but not just to the barin tissue, but lacerations of the small blood vessels as well, with contusional areas such as hipodensic or hiperdensic zones on CT. Signs and symptoms are: - focal seizures, including epilepsy - focal neurological issues - somnolence or coma - long term coma - posttraumatic psychosis Treatment includes: - Conservative (depending on the severity of the injury) with antiedematous therapy: manitol 10%, lasix 10%, glucose, corticosteroids (Dexazone) and the use of respiratory support when needed.

INTRACRANIAL COMPRESSIVE SYNDROMES / HEMATOMAS Three separate conditions can result from craniocerebral trauma: - Acute epidural hematoma (Haemathoma cerebri epiduralis),

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Studentsâ&#x20AC;&#x2122; Association - Macedonia 1st Summer School on Emergency Medicine - Subdural hematoma (Haemathoma cerebri subduralis), - Intracerebral Hematoma (Haemathoma intracerebralis).

Epidural Hematoma (Haemathoma epiduralis) Is a blood accumulation between the dura mater and the periost of the scull. 0.4-5% of all CCI. The cause for ocurrence is arterial bleeding (most often a. Meningica media), as a result form a linear fracture to the scull (70%) Localisation: Temporal region (most often), frontal region (9-17%), Occipital region (3-12%) The manifestation in its acute form takes place 12 hours after the injury, or after 24-48 hours, as a chronic form. Clinical findings: -

Loss of consciousness after the trauma

Free interval without symptoms, after

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Students’ Association - Macedonia 1st Summer School on Emergency Medicine which: -

There is another loss of consciousness,

Asymmetrical pupils (anizo-choria, Hutchinson’s pupils)

Contralateral hemiparesys (plegia)

Headache with vomitus (unspecific)

Diagnosis is confirmed with: - Clinical findings and a CT – golden standard Treatment is surgical (trepanation and evacuation of the hematoma) Subdural hematoma (Haemathoma subduralis) A condition of blood accumulation between the dura mater and the arachnoidea. It may manifest as: - Acute (70% lethal) - Chronic (90% of all) Acute subdural hematoma is part of : - brain contusion - meningial injury - injury to the brain blood vessels Clinical sings develop quickly (immediately or after several hours), without the free interval, and with hemiparesis and loss of concsiousness The Diagnosis is based on: Clinical findings and CT

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Studentsâ&#x20AC;&#x2122; Association - Macedonia 1st Summer School on Emergency Medicine The Therapy is surgical (trepanation and evacuation of the hematoma) The Chrnoic subdural hematoma is manifested after a lucid interval of several days, weeks or even months. It occurs mostly due to vein trauma. Clinically we see: -

Headache

Vomitus

Papillary edema

Loss of consciousness

Focal seizures

Hemiparesis (plegia)

Intracerebral hematoma This occurs as a result of laceration and injury to the intracerebral blood vessels. The clinical findings occur very quickly, with loss of consciousness â&#x20AC;&#x201C; coma (62% lethality at comatose patients) and neurologic seizures (hemiplegia and hemiparesis), with heavy morbidity. The Diagnosis is based on: -

Clinical findings and CT

Therapy is surgical (trepanation and evacuation of the hematoma) The diagnosis is based on: - Clinical findings and head CT

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Studentsâ&#x20AC;&#x2122; Association - Macedonia 1st Summer School on Emergency Medicine CARDIOPULMONARY RESUSCITATION - CPR How To Perform CPR CPR is a life saving procedure that combines rescue breathing, which provides oxygen to the lungs and chest compressions, which stimulates the heart to resume beating. In order to perform CPR successfully, itâ&#x20AC;&#x2122;s important to be sure to follow a set of procedures in order to maintain calm during the crisis and keep the victim alive until medical professionals arrive. Definition of CPR CPR stands for cardiopulmonary resuscitation. It is an emergency procedure that serves as a life saving method. Artificial respiration is performed to keep oxygen flowing through the blood. Intermittent external chest compressions massage the heart and stimulate it to resume pumping the artificially oxygenated blood to the brain. Without this procedure, permanent brain damage or death can occur within minutes. When the heart stops, the brain is deprived of the oxygen it needs to continue functioning and keep the body alive. CPR is the first treatment for someone who has passed out, has no pulse, and is also not breathing. If the victim still has a pulse, only artificial resuscitation is necessary. Continue CPR or artificial breathing alone until the victimâ&#x20AC;&#x2122;s breathing and pulse resume on their own or until medical professionals arrive to take over. Make Sure the Scene is Safe Before you begin performing CPR, there are certain steps you must take to be sure that more harm will not come to the victim and that no harm will come to you. It is imperative that you check the locale for safety hazards and attend to them promptly so that more victims are not created while you are helping the first one. Do not hesitate to tell others what to do. If everyone waits for someone else to take the lead, nothing will get done. Time is of the essence in an

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Studentsâ&#x20AC;&#x2122; Association - Macedonia 1st Summer School on Emergency Medicine emergency situation where someone is not breathing and has no pulse. Courtesy is not. Have someone else call 911. If you know how to perform CPR, you should not waste time on the phone if someone else can do it. If you are the only person around and have a phone available to you, call but continue preparations. Avoid safety hazards in the environment of the victim, like fire or a downed power line. If you can fix any of the immediate issues or have someone else do it, then secure these things before continuing to perform CPR. If you can get to the victim safely, do so. If you injure yourself, no one is helped and another victim is created. If the victim needs to be moved because of some imminent danger, move them â&#x20AC;&#x201C; carefully and quickly. Try to keep their neck as immobile as possible but when you have to choose between a possible spinal injury and death, take the chance and move that victim to a safer place to perform CPR. When To Use CPR Once the area is secure and no harm is immediately recognizable, it is necessary to figure out what injuries the victim has suffered, which are the most serious, and deal with them in order of most importance. Check to see if the victim is conscious. If so, ask them what hurts and what their name is as you check for injuries. If they are conscious, do not perform CPR. If they are unconscious, make sure that their airway is open and that they are breathing. If they are not breathing, perform artificial breathing. If they are breathing, do not perform CPR. Check their pulse. If there is no pulse, perform CPR. If there is a pulse, but the victim is not breathing, perform artificial resuscitation only. Even if the victim is bleeding heavily, deal with breathing and pulse problems first. Heartbeat and oxygen are the most important things to focus on. This may seem like an obvious pointer, but absolutely DO NOT perform CPR if the victim has a pulse and/ or is breathing. Sometimes people get carried

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Students’ Association - Macedonia 1st Summer School on Emergency Medicine away in an emergency and do what they know – whether or not it is necessary. Be sure to hold the victim’s head motionless while checking the airway, breathing, and pulse. If possible, have someone else do it for you so that you can focus on CPR as necessary. If at all possible, try to record what happens. Whether it’s a scrap of paper that you scribble on out in the woods or you have someone else do it, any information you have will help medical personnel when they arrive. You don’t want to forget life saving details in the heat of the moment. ABC ABC is an acronym to help you remember the important first steps before performing CPR: airway, breathing, and circulation. Open the airway, check the victim’s breathing, and pulse (i.e. circulation). To open the victim’s airway, lift the chin carefully. This will move the jaw forward and tilt the head backward, allowing a path for air to travel to the lungs from the mouth and nose. Remember – don’t push the forehead back in an effort to open the airway. If the victim has a neck or spinal injury, this will only make it worse. To check for breathing, watch the victim’s chest. If you can see it rise and fall even slightly, then they are breathing. Whether or not you can see the chest rise and fall, listen with your ear to the mouth and nose. You are listening for breathing sounds. If you can’t hear the victim breathing, but can feel their breath on your ear, then they are breathing. Use as many senses as possible and your best judgment. To check circulation, feel for a pulse. Press two fingers gently on the victim’s neck between the Adam’s apple and the muscle and the side of the neck. Don’t use your thumb, because your thumb has a pulse of its own. To check an infant’s circulation, press two fingers between the armpit and elbow on the inside of the baby’s arm.

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Students’ Association - Macedonia 1st Summer School on Emergency Medicine Remember, if your search for breathing and circulation yield nothing, have someone call 911 or call them yourself if you are the only conscious person in the room, and immediately begin compressions and artificial breathing. Check the Results of Artificial Breathing We’ve discussed how to open the airway and check for breathing. If there is no breathing, you will need to begin breathing for the victim immediately. Keep the airway open and pinch the victim’s nose shut hard enough to be sure that no air will escape. Seal their mouth with yours and give two long breaths, slowly. If the breaths don’t make the victim’s chest rise, then re-tilt the victim’s head. Seal their mouth with yours again, pinch the victim’s nose, and offer two long breaths again, watching out of the corner of your eyes to see if their chest rises. If the chest still doesn’t rise, the airway might be blocked. If Artificial Breathing Doesn’t Work If the breaths you are giving the victim are not making the chest rise, you are sure that you have pinched the nose completely closed, sealed their mouth with yours, and offered the breaths strongly enough, then you must check the airway to see if it is obstructed. Put your index finger underneath the victim’s chin and your thumb inside their mouth on top of their tongue. Squeeze your index finger and thumb and pull the lower jaw (and tongue) down toward the victim’s chest. The goal of this step is to push the tongue down as far as possible so that you can clearly see down the victim’s throat. If you have a pen light or small flashlight, use it to look for the object obstructing the victim’s airway. If you can see it, use the index finger of the hand that is not holding the jaw and tongue down to sweep the object out of the throat. This should unblock the airway.

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Students’ Association - Macedonia 1st Summer School on Emergency Medicine Begin artificial breathing again by pinching the nose, sealing the mouth with your own, and breathing twice, slowly, watching out of the corner of your eye to see that the chest moves. Continue offering breaths to adult victims once every 5 seconds until the victim begins breathing autonomously, medical help arrives, or you can continue no longer. For infants, follow the above steps but place your mouth over the baby’s mouth and nose, instead of pinching the nose and sealing the mouth. All of the above steps apply to infants and children up to 8 years old, except the breath cycles. Offer a breath every 3 seconds until help arrives or the child begins breathing on its own. Be sure that you don’t breathe too hard for infants and children. Breathe just hard enough that their chest rises gently.

No Pulse and No Breath? Then it’s time to perform CPR. Find the lowest tip of the breastbone. Position the heel of your hand two finger widths toward the head. Place your other hand on top of the first hand and interlace your fingers. Sit up and lean over so that your shoulders are directly above your hands. Using your shoulders and upper body, push down on the chest (a compression) 15 times in 10 seconds. Stop compressions and give two slow breaths. Give adults 15 more compressions in 10 seconds followed by two slow breaths, repeating this 4 times. Check for pulse and breathing. For children up to age 8, give 5 compression in 3 seconds followed by one slow breath, repeating 12 times before checking for pulse and breathing. NOTE: Do not offer as much force during compressions for children as for an adult. Continue this until the victim’s pulse and breath return or medical personnel arrive on the scene.

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Students’ Association - Macedonia 1st Summer School on Emergency Medicine Infants The only difference between adult and child CPR is the number of compressions and breaths per cycle and the amount of force used during compressions. Infants have a few more differences. Place your index, middle, and ring fingers directly between and just below the infant’s nipples. The pads of your fingers should be facing you. Lift your index finger, but keep your middle and ring fingers in place and offer the same number of compressions and breaths as for children: 5 compressions in 3 seconds followed by one slow breath in cycles of 12. Between cycles, check for breathing and pulse. Continue until professional help arrives or the infant begins breathing or regains a heartbeat. If a child has been struck by lightning or was drowning when you found him or her, properly performed CPR has an excellent chance of helping the child regain a heartbeat and breathing. Don’t give up! And don’t forget to offer less force during compressions for children and infants. You don’t want to crack a rib! Tips If the victim has a mouth or lip injury, then close the mouth and seal it shut with your hand while offering breaths through the nose. Watch out of the corner of your eye while delivering breaths to be sure that the chest is rising gently. This will show you that the breaths are making it to the lungs and that the airway is not obstructed. Try to use your upper body weight when giving compressions so that you don’t tire as quickly. If there is someone else present who also knows CPR, trade off while you wait for emergency personnel. It will help keep you from getting tired too quickly. If the victim vomits, turn them on their side. When they are finished, clean their mouth and roll their onto their back so that you can continue artificial breathing.

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European Medical Students’ Association - Macedonia 1st Summer School on Emergency Medicine Diseases are transmitted through body fluids and the air. Be as safe as possible and wear safety gear like latex gloves, plastic goggles, or a surgical mask if you have them available. Keep everything that touches the victim as sanitary as possible. Do not let this article be your only guide. Contact your local American Red Cross chapter for a schedule of CPR classes in your area.

URGENT PROCEDURES IN THORACIC SURGERY The most common condition in the thoracic surgery is the trauma of the chest. Because of the location of the thorax and its inner vital organs, the chest injuries are considered as serious and could be life-threatening. The chest trauma is not that often (10 %), but because it is followed by high morbidity and mortality the injuries must be treated in hospital. Phases of Initial Assessment Primary Survey (15 seconds) Airway with C-spine control → Voice, air exchange, patency, cervical immobilization Breathing → Breath sounds, chest wall, neck veins Circulation → Mentation, skin color, pulse, blood pressure, neck veins, external bleeding Disability (neurologic) → Pupils, extremity movement (site and type), voice Expose the patient

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European Medical Students’ Association - Macedonia 1st Summer School on Emergency Medicine Resuscitation Generic—ECG leads, pulse oximetry, IV, draw labs Concurrent with life-threatening injuries identified on primary survey Include gastric and urethral catheters, or perform with secondary survey Secondary Survey Head-to-toe examination (including spine) AMPLE history (A = allergies, M = medications currently taken, P = past illness, L = last meal, E = events related to injury) Imaging Second survey may be delayed until after OR in unstable patient or patient in extremis Definitive Care Surgery (may be in resuscitation phase) Splinting Medications (3 A's): analgesics, antibiotics, antitetanus Consultants Transfer Tertiary Survey Repeat primary and secondary surveys within 24 hours for occult or missed injuries. Create injury “problem” list with specific identification of physician handling each.

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European Medical Studentsâ&#x20AC;&#x2122; Association - Macedonia 1st Summer School on Emergency Medicine Urgent procedures: -

Cricoidectomy Tracheostomy Pleural punction Thoracic drainage Thoracocentesis Thoracic wound treatment Urgent thoracotomy Conditions when a treatment of airways is needed:

SaO2< 90% PaO2< 60 mmHg on 40% O2 Respiratory rate > 35 PaCO2> 55 mmHg Vital capacity < 15 mL/kg A-a gradient > 350 mmHg on 100% O2 Cricoidectomy Providing the airway is the most important thing for maintenance of life. The Cricoidectomy is especially important when the intubation of the patient is difficult or impossible. 7 % of traumatized patients request the intervention of Cricoidectomy.

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European Medical Studentsâ&#x20AC;&#x2122; Association - Macedonia 1st Summer School on Emergency Medicine

The cricoidectomy is a surgical method of choice for providing airway in urgent conditions when the intubation or other methods of providing airway are impossible or contraindicated. Contraindications: -possible intubation

-laryngeal trauma

-partial or total transaction of airway Instruments needed: -sterile gloves

-small scalpel

-syringe and needle

-hook for trachea

-dilatator

-betadine, local anesthetic, suture material

-tracheostomy keaneally

At young children (until 10 years old), cricoidectomy can be performed with needle. With this method the ventilation can be maintained for 72 hours. Cricoidectomy is a life-saving procedure. It provides ventilation and access of oxygen in the airways, when other methods are impossible. It is a cheap and realistic method which could be performed in a few minutes and saving a life. Tracheostomy Urgent surgical procedure, which provides airway for a longer period. It is performed in total or local anesthesia. It is actually setting of the tracheostomy keaneally in the trachea (cervical part).

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European Medical Studentsâ&#x20AC;&#x2122; Association - Macedonia 1st Summer School on Emergency Medicine The trachea is an organ which conducts the air from the larynx to the left and right main bronchus. It is 10-11 m long, 2,5 cm wide. It is located in the cervical region under the skin, soft tissues, platisma, pretracheal fascia and in the upper partsisthmus of the thyroid gland. It consists of 16-18 cartilage rings. Clinical Indicators for Performing a Tracheostomy, as Proposed by the American Academy of Otolaryngologyâ&#x20AC;&#x201C;Head and Neck Surgery

Upper airway obstruction, including Obstructive sleep apnea Bilateral vocal cord paralysis Need for prolonged mechanical ventilation Inability of patient to manage his or her secretions Facilitation of ventilation support Adjunct to manage head and neck surgery Adjunct to manage head and neck trauma Difficulty with intubation and need for airway

It is considered that the tracheotomy is a method of choice for treatment of upper airway obstructions, epiglottis, cervical infections, lacerations of the basis of oral cavity, foreign bodies, facial fractures. Indication for urgent tracheostomy is: laryngotracheal trauma with disruption of airway, need for airway at children. Contraindications: -sterile gloves skin retractors

-syringe and needle

-small scalpel

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

-hook for trachea

European Medical Studentsâ&#x20AC;&#x2122; Association - Macedonia 1st Summer School on Emergency Medicine -Tissue retractors -scissors -needle holder -peans -dilatators -tracheostomy keaneally -betadine, local anesthetic, suture material

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European Medical Studentsâ&#x20AC;&#x2122; Association - Macedonia 1st Summer School on Emergency Medicine Since 1985 a percutaneous tracheostomy is introduced, which is less invasive and less traumatic. It may request use of flexible bronchoscope for control of the keaneally setting. Today there are special designed sets. As a consequence of the tracheostomy some complications may occur: Complications of Tracheostomies

Immediate

Delayed

Postoperative

Hemorrhage

Disrupted tract

False passage

Tracheal stenosis

Displaced tube

Damage to surrounding Subglottic stenosis structures

Obstructed plugging

Recurrent nerve

laryngeal Tracheoinnominate artery fistula

Delayed hemorrhage

Esophagus

Tracheoesophageal fistula

Posterior perforation Common artery

tracheal Fused vocal cords

mucus

Subcutaneous emphysema Mediastinal emphysema

carotid Delayed wound problems Infection: wound, tracheitis, mediastinitis, pneumonia

Internal jugular vein Anterior jugular vein

Excess tissue

granulation Aspiration

Persistent stoma

Pleura, pneumothorax Cricoid Air embolism Apnea

tube,

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European Medical Studentsâ&#x20AC;&#x2122; Association - Macedonia 1st Summer School on Emergency Medicine Cardiac dysrhythmias Cardiac arrest

Pleural puncture (with needle, braonila) The tensed pneumo thorax is a progressive unilateral collection of air in the pleural space. The air enters as a result of a lung injury, thus creating a valvua mechanism, it enters but it canâ&#x20AC;&#x2122;t exits. As a consequence of that, first the lung collapses from the side, followed by displacement of the heart and the mediastinal organs towards the other side with compression and reduction of the function of the healthy lung. In the pleural gap instead of a negative pressure there is a strong positive pressure. The removal of air with puncture of the pleural space with a needle and air decompression with a lung deexpansion is knows as a pleural punition with a needle and this procedure is an urgent procedure. The tensed pneumothorax should be immediately recognized and properly treated. Suspicion of a tensed pneumo thorax should indicate a prior history of disease, the existence of injury, physical examination and critical condition of the patient. The treatment should not be delayed with additional diagnostic procedures. These are patients with sudden cardiovascular deterioration, which is manifested with a sudden respiratory insufficiency, pain chest, lack of air, hypotension, tachycardia, unilateral lack of breathing, hypersonar percussion, increased central vein pressure with expressed neck veins, hypoxemia, cyanosis ,deviation of the normal heart beating, deviation of the normal location of the trachea. The cause can be: chest trauma (muted or penetrant ), lung injury during mechanical ventilation, or, placement of a central venous catheter.

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European Medical Studentsâ&#x20AC;&#x2122; Association - Macedonia 1st Summer School on Emergency Medicine On a lying patient the braonila is placed in the second intercostals space , in the medioclavicular line (above the third rib).After the penetration of the pleura, the drainage is being removed and the plastic part remains inside. If there is a tense pneumo thorax through the braonila comes out an air under pressure. After the emersion of the air, the clinical picture is significantly improved. In the tensed pneumothorax after the placement of the needle in the pleural space the tensed pneumothorax is solved, a life is saved, but it turns into habitual pneumothorax that should be further treated by placing the chest drainage in the pleural space. Thoracic drainage The thoracic drainage is a surgical procedure of placement of a thoracic drain in the pleural space in order to remove fluid, blood, air from the pleural gap. In a thoracic trauma, a surgical treatment in terms of thoracotomy was indicated that 10-20%, and in other cases it is used as a diagnostic as well as a therapy option for treatment of injuries in the chest area. The presence of air in the pleural area is known as pneumonic thorax. The presence of air in the pleural area under pressure which compresses the mediastumum towards the healthy side is known as a tensed pneumonic thorax. The presence of fluid in the pleural space is known as liquido thorax. The presence of blood in the pleural area in known as hemato thorax. The traumatic injuries of the chest can cause a hemothorax as a result of an injury of the chest wall, broken ribs, injury of the intercostals blood vessels, chest injury and injury of other organs.

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European Medical Studentsâ&#x20AC;&#x2122; Association - Macedonia 1st Summer School on Emergency Medicine Indicators for placement of thorax drainage are pneumonic thorax, liquid thorax, hemato thorax, hematopnemunomia thorax, chylothorax, empyiema and other conditions. Contra indicators for placement of a drain are conditions with a disturbed hemostasis, existence of large bullosis , outbursts, TBC , previous drainage. The thorax drain is placed with a local anesthesia. It is set in the second intercostal space in the medioclaviclar line, if we have a case of pneumoniac thorax, and if we have a case of irruption in the pleural area it is placed in the fifth intercostal space in the middle axial line. In cases of imitated outbursts the drain can be placed where the burst is located, detected under ultrasound control. Necessary equipment and instruments:

Sterile gloves syringe and needle

small scalpel syringe holder peans thorax drain drainage system betadine, local anesthesia, sutura material surgical dressing

Thoracocenthesis It is a method for removal of fluids from the pleural space. It is performed with local anesthesia and it is consisted of placement of the braonila in the pleural area connected with a system. The outburst of the pleural area is a result of a disease of the surrounding structures, it is primary a diagnostic procedure and second it is a therapy procedure. Through the thoraxcenthesis needle a slim catheter can be placed which is used as a

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European Medical Studentsâ&#x20AC;&#x2122; Association - Macedonia 1st Summer School on Emergency Medicine therapy for pleural outbursts. The procedure is performed with a local anesthesia with placement of the needle in the pleural area through the upper edge of the rib. Emergency Thoracotomy The position of the vital organs in the chest cavity leads to serious injuries of the chest which require adequate and fast patient transportation. Only 10 â&#x20AC;&#x201C; 20% of the injuries to the thorax require emergency thoracotomy. Its purpose with unstable patients is to provide hemostasis, take the load of a pericardial tamponade, clamping the aorta (for blood re-distribution to the brain and heart) as well as giving the possibility for open chest heart compressions. The emergency thoracotomy is a surgical intervention done in the OR, under a general anesthesia. Indications for its use are: penetrant trauma to the thorax with still present, though seriously inhibited life signs. Non-existence of life signs advises against thoracotomy. The procedure, as above mentioned, is done under general anesthesia, with a left anterolateral insicion through the sixth intercostal space, which provides entrance to the left hemithorax, as well as the pericardia which is immediately opened. If needed, the right thorax may be accessed by transversal cutting of the thorax, which opens up the mediastinum and heart as well. A thoracotomy set with vascular atraumatic clams is necessary for the procedure.

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European Medical Studentsâ&#x20AC;&#x2122; Association - Macedonia 1st Summer School on Emergency Medicine PNEUMOTHORAX By definition, pneumothorax is a collection of air in the pleural cavity. In normal conditions, although there is a negative pressure between the two pleurae, air does not enter from outside the lungs. The air in the pleural cavity gets there if there is a communication between the alveoli and the pleural cavity; or if there is a communication of the pleural space with the atmosphere; or if there is a foreign body, a piece of tissue in the pleural space producing air. As a result of the entering air in the pleural cavity, the lung collapses and it might be partial (partial pneumothorax) or total (total pneumothorax). Most often pneumothorax is developed unilaterally and rarely bilaterally. It is partial if the lung is partially collapsed (Fig. 24.1) or total, if the lung is completely collapsed in the hilus (Fig. 26.2). Regarding the etiology of the pneumothorax, it is divided into: 1) Spontaneous; 2) Traumatic; 3) Iatrogenic.

1) Spontaneous pneumothorax occurs without any obvious external cause and it can be divided into: a) primary pneumothorax,

spontaneous

b) secondary pneumothorax.

spontaneous

a) Primary spontaneous

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European Medical Students’ Association - Macedonia 1st Summer School on Emergency Medicine pneumothorax is an accumulation of air in the pleural space in the absence of any clinically underlying lung disease. A rupture of the subpleural bullae is the most common cause for this type of pneumothorax, but almost in 30% of the cases there is no macroscopically obvious cause for the appearance of pneumothorax (idiopathic).

Figure 24.1. CT image of partial pneumothorax …Pneumothorax arises more frequently in tall slim young males (the peak is around their twentieth year of life). Smoking increases the risk for onset of a primary spontaneous pneumothorax. A secondary spontaneous pneumothorax occurs due to known underlying lung diseases. Almost all lung diseases might be complicated with pneumothorax resulting in severe conditions in a large percentage since pneumothorax arises when there is an already existing respiratory insufficiency. Table 24.1. presents the most common diseases where a secondary spontaneous pneumothorax might appear.

Figure 24.2. Total pneumothorax – x-ray of the chest 2) Traumatic pneumothorax is a result of blunt or penetrating injury to the chest and it can develop during the injury, immediately after it or later. In blunt injuries, pneumothorax can occur due to laceration of the pleura and pleural parenchyma from the fractured fragments of the ribs, but more often it is caused by a rupture of the alveoli or bullae as well as by laceration of the visceral or mediastinal pleura due

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European Medical Studentsâ&#x20AC;&#x2122; Association - Macedonia 1st Summer School on Emergency Medicine to a sudden compression of the chest. It can also develop as a result of laceration of the trachea or of the large bronchi. If mediastinal pleura is lacerated, subcutaneous emphysema can appear. The mechanism of onset of a pneumothorax in open injuries to the chest is well-known: through an open wound in the chest air enters directly into the pleural cavity where the pressure is negative. Table 24.1. The most common diseases that can lead to secondary spontaneous pneumothorax (presented by the frequency of their onset) Diseases of the respiratory tract Chronic obstructive pulmonary diseases Cystic fibrosis Acute severe asthma Infectious lung diseases Echinococcosis Pneumocystis carini pneumonia Tuberculosis Necrotizing pneumonia Interstitial lung diseases Sarcoidosis Idiopathic pulmonary fibrosis Histiocytosis X Lymphangioleiomyomatosis Connective tissue diseases Rheumatoid arthritis Ankylosing spondylitis Polymyositis / Dermatomyositis Scleroderma Marfan syndrome Malignant diseases Bronchogenic carcinoma Sarcoma

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European Medical Studentsâ&#x20AC;&#x2122; Association - Macedonia 1st Summer School on Emergency Medicine Pneumothorax caused by trauma can be: a) b) c) a)

Simple Open Ventile Simple pneumothorax most often occurs following an injury of the lung parenchyma from fractured parts of the ribs, stabbing or gun injuries to the chest, when alveoli are damaged and air enters the pleural space. b) Open pneumothorax is a result of the open communication between the pleural space and the outside. Shortness of breath in this situation depends on the size of the pneumothorax (the amount of air that leaks) and on the previous general condition of the injured person. c) Ventile, also referred to as tension pneumothorax, is the most dangerous type, which can cause death in no time. There is a valvular mechanism on the chest injury, where during inspirium air enters the pleural cavity, while during expirium the air does not go out due to the valvular mechanism, the result of which is increased intrapleural pressure with lungs collapse, mediastinum pressing towards the healthy side; in addition compression and collapse of v. cava superior et inferior could appear which prevents blood delivery in heart, the result of which is cardiac arrest (Figure 24.3).

Figure 24.3 Ventile pneumothorax â&#x20AC;&#x201C; x-ray 3) Iatrogenic pneumothorax appears as a result of complication of diagnostic or therapeutic procedures. The percentage of iatrogenic pneumothoraces has increased lately as a result of much greater use of invasive diagnostic procedures. Iatrogenic pneumothorax is most frequently caused by a complication during transthoracic

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European Medical Students’ Association - Macedonia 1st Summer School on Emergency Medicine puncture biopsy, central vein catheterization – particularly of subclavia, thoracocentesis, mechanic ventilation with positive pressure, pleural biopsy and transbronchial biopsy. Special types of pneumothorax Catamenial and neonatal pneumothoraces are presented as special types of pneumothorax because of the specific pathophysiologic mechanisms of their development. Catamenial pneumothorax appears in women in their reproductive period (most commonly in women aged 30 - 40 years). It is characteristic that it appears in the first 24-72 hours after menstruation, it is often recurrent and most usually it appears on the right side, seldom on the left side and almost never on both sides. Great number of women also have pelvic endometriosis with pleural or diaphragmal location of lesions. There is another hypothesis of occurrence of catamenial pneumothorax: during menstrual period air enters the peritoneal cavity, which through defects in the diaphragm, provide entry into pleural cavity. Neonatal pneumothorax appears in newborns immediately after their birth. It is more common in severe forms of delivery with aspiration, in distress syndrome and in premature newborns treated with artificial ventilation (Figure 24.4).

Figure 24.4 Neonatal pneumothorax –x –ray

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European Medical Studentsâ&#x20AC;&#x2122; Association - Macedonia 1st Summer School on Emergency Medicine Signs and symptoms of pneumothorax Pneumothorax is manifested with chest pain that is acute and on the same side as the affected lung, shortness of breath, coughing, and depending on the type and stage of the pneumothorax, respiratory insufficiency may develop. Other rare symptoms include: hypotension, tachycardia and cyanosis suggestive of ventile pneumothorax. In secondary pneumothorax clinical picture is often more severe because of the existing lung diseases. Sometimes it can have minor symptoms or it can be asymptomatic. Diagnosis If signs and symptoms of a pneumothorax are recognized and assessed and if the doctor has in mind this disease, then its diagnostics is very simple and quick. On auscultation, there is decreased or absent breath sound on the same side as the pneumothorax. Final diagnosis is made by chest x-ray in both directions illustrating the collapse of the lung; the margin of the visceral pleura is seen and peripheral there is an intensive darkness with absent bronchovascular image. If the pneumothorax is of older date, hydroaeric level of the present liquidopneumothorax might be found. CT of the chest is rarely advised in doubtful partial pneumothoraces (Figure 24.5). In order to define the exact treatment of a pneumothorax, it is very important to determine the exact cause for the appearance of the pneumothorax. This is especially important for the primary spontaneous pneumothorax. In all these cases, diagnostic thoracoscopy is indicated during initial drainage. Based on the thoracoscopic findings, patients are classified in four stages by Vanderschueren, modified by Boutin, and presented in Table 26-2. Thoracoscopic finding is essential in defining the treatment of patients with pneumothorax. Underlying lung diseases have to be taken care in secondary and iatrogenic pneumothoraces and caution is necessary regarding the eventual associated injuries

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European Medical Studentsâ&#x20AC;&#x2122; Association - Macedonia 1st Summer School on Emergency Medicine in traumatic pneumothorax. In case of catamenial pneumothorax, thoracoscopy is advised for observing the eventual diaphragmal defects.

Treatment of Pneumothorax Surgery is recommended, having in mind the three objectives that should be achieved with the treatment: to evacuate the air from the pleural space in order to establish a negative pressure; to accomplish a complete re-expansion of the lung; to reduce the risk of recurrences.

Table 24.2. Thoracosopic staging in pneumothorax Stage 1

Endoscopic normal lungs; idiophatic pneumothorax

Stage 2

Pneumothorax with pleuropulmonal adhesions

Stage 3

Pneumothorax with bullae of d<2cm

Stage 4

Pneumothorax with bullae of d<2cm

Nevertheless, it should be noted that there are also conservative approaches in the treatment of pneumothorax, which means to evacuate the air with pleural puncture! The author of this text does not support this concept. Observation is recommended in minimal partial pneumothoraces (up to 10%). It is seldom used due to slow air absorption.

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European Medical Studentsâ&#x20AC;&#x2122; Association - Macedonia 1st Summer School on Emergency Medicine Thoracic drainage is a method of choice in the treatment of pneumothorax. It is initial treatment which is quick, and at the same time effective and safe therapy. It is performed under local anesthesia and the chest tube is placed through the second intercostal space at medioclavicular line or through the fifth-sixth intercostal space at mid-anterior axillary line. It has already been mentioned that in performing drainage it is advisable to make diagnostic thoracoscopy in order to resolve some etiologic dilemmas and to indicate the best therapeutic approach. In the first stage and during the first attack thoracic drainage alone is performed, while in recurrences talc poudrage is used, which can be slurry but it is more effective with VATS. In the second stage thoracic drainage is also performed, and if possible, it is good to divide pleuropulmonary adhesions by thoracoscopy.

(Figure 24.6, - VANDERSCHUEREN modification of BOUTIN table VII

In the third stage of pneumothorax, thoracic drainage can be performed and either cauterization of small bullae or thoracoscopic ligation with loop.

Figure 24.7 Thoracoscopic loop ligation of bullae

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European Medical Studentsâ&#x20AC;&#x2122; Association - Macedonia 1st Summer School on Emergency Medicine (Figure 24.7). Talc pleurodesis is indicated in recurrences of the second and third stages. In patients thoracosopic findings of bigger than 2 cm

with bullae

Figure 24.9. Thoracoscopic wedge stapler resection (Figure 24.9) is performed in both methods. In addition, either pleurectomy

Figure 24.10 Thoracoscopic pleurectomy

(Figure 24.10) or abrasion of pleura can be made.

According to some authors, indications for surgery of pneumothorax include: persistent air leak, recurrent pneumothorax,

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European Medical Studentsâ&#x20AC;&#x2122; Association - Macedonia 1st Summer School on Emergency Medicine first episode in patients with previous pneumonectomy, first episode in pilots and divers. We support the attitude that the choice of method for treatment based on thoracoscopic morphologic finding is more contemporary and more adequate. . Traumatic pneumothoraces are often associated with hemothorax and the therapy consists of placing thoracic drain/tube, while thoracotomy is indicated if thoracic drainage fails due to the nature of the injury. The open pneumothorax should be closed and thoracic drain should be inserted/placed. In case of ventile pneumothorax urgent drainage is needed, sometimes in improvised conditions because of the life-threatening condition of the patient. Catamenial pneumothorax is managed with thoracic drainage; medicines are given to control/prevent menstruation. However, today VATS pleurectomy and talcation are more often used for eventual closing of defects/holes in the diaphragm. The results from the surgical treatment of pneumothorax are excellent with minimal percentage of recurrences, which has practically been confirmed in our practice. Minor complications appear rarely.

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European Medical Studentsâ&#x20AC;&#x2122; Association - Macedonia 1st Summer School on Emergency Medicine EMERGENCY GYNECOLOGY

Introduction General surgeons in the developing world have to be versatile in diagnosing and managing abdominal disorders, not just involving the GI tract, but also those of other organ systems such as the genitourinary tract. Common gynecologic emergencies can mimic general surgical conditions such as cholecystitis and appendicitis. Most patients with gynecologic emergencies complain of pelvic pain and/or abnormal vaginal bleeding. A complete history and physical exam will define the extent of the laboratory and radiologic work up and the expediency of resuscitation. Most gynecologic emergencies arise from benign rather than malignant etiologies.

Abnormal Pregnancies

1.1 Forms of abortion 1.1 Spontaneous abortion Approximately 20% of known human pregnancies terminate in a recognized abortion. Eighty percent of spontaneous abortions occur in the first trimester and are usually a result of chromosomal or genetic abnormalities. The risk factors for a spontaneous loss include prior pregnancy loss: history of one abortion (13%); two prior abortions (25%); three prior abortions (45%) and 4 prior abortions (54%) and rising maternal age (women 35-40 yr (21%); women over 40 yr (42%). 1.2 Threatened Abortion These women present less than 20 weeksâ&#x20AC;&#x2122; gestation with crampy, abdominopelvic pain, vaginal spotting, no cervical dilation or effacement and an intact intrauterine pregnancy. The management includes restricting activities. There is no evidence that progesterone or injectable HCG will improve outcome. Serial bHCG and ultrasonography will aid in predicting outcome.

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European Medical Students’ Association - Macedonia 1st Summer School on Emergency Medicine 1.3 Inevitable and incomplete abortion Those women with an inevitable abortion present with an open cervical os on pelvic examination but without a history of passing tissue. The women with an incomplete abortion have evidence of retained products either by examination or ultrasound. These cases usually occur between 8 and 14 weeks of pregnancy, are incomplete and require surgical evacuation. If the woman’s vital signs are stable, then treatment includes: CBC, group and screen and possibly cross match, insertion of a large bore IV, oxytocin (10-30 units in 1000ml of Ringers lactate), analgesia, and a paracervical block with 1% lidocaine (10cc). The goal is to evacuate the uterine contents with suction (vacuum aspiration). Intercourse should be avoided for 2 weeks. Iron supplementation should be considered. If the mother is Rh negative and father Rh positive, give 50 microgram of anti-D gamma globulin IM. 1.4 Ectopic Pregnancy Any pregnancy not in the uterus is considered ectopic. Ninety-five percent of ectopic pregnancies are tubal, less commonly on the ovary or the peritoneum. Late diagnosis leading to major complications and the necessity of emergency surgical treatment are most important. Risk factors include: prior ectopic pregnancy, infertility, prior pelvic inflammatory disease (PID) or sexually transmitted disease (STD), intrauterine device (IUD), past or present smoker, documented tubal pathology, or multiple sexual partners. Only one third of patients are diagnosed on initial evaluation. Any woman with pelvic pain and vaginal bleeding should be screened with serum or urine human chorionic gonadotrophin (ßHCG). Quantitative serum bHCG is an extremely valuable tool for assessing pregnancy. Produced by the syncytiotrophoblast 8 days after fertilization, bHCG rises progressively to reach a peak 65 days after conception reaching levels as high as 100,000mIU/ml. HCG has a half life of 1.5 days. Its quantitative value plays an important role in the diagnosis and decision making around a number of emergency gynecologic conditions: abortions, GTD and ectopic pregnancy. Sadly, quantitative tests are not available in the majority of hospitals in the developing world and physicians are obliged to make decisions using qualitative urinary tests with a higher level of false negatives. The woman may have no symptoms. If symptoms are present they may include abnormal vaginal bleeding (in 50-80% of patients), abdominal pain (in 90100% of patients), shoulder tip pain (which reflects blood in the peritoneal cavity), and amenorrhea.

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European Medical Studentsâ&#x20AC;&#x2122; Association - Macedonia 1st Summer School on Emergency Medicine On exam, an adnexal mass is present in only one-third of patients. The presence of peritoneal signs, cervical motion tenderness and lateral or bilateral abdominal or pelvic tenderness increases the likelihood of an ectopic pregnancy. Hypotension strongly suggests a ruptured ectopic. Tachycardia unfortunately is only seen in half of the patients. In the other 50% of patients with hypotension and a normal heart rate, the hematoperitoneum has triggered a parasympathetic response preventing increase in the heart rate despite significant volume loss. 2.0 Ovarian Masses 2.1 Tubo-ovarian Torsion Acute adnexal torsion accounts for 3% of all emergent gynecologic surgeries. Complete or partial torsion of the ovarian vascular pedicle compromises the lymphatic and venous drainage (presents as unilateral tender adnexal mass) with eventual loss of arterial perfusion (low grade fever and leukocytosis). The risk factors include: pregnancy, ovarian stimulation; and ovarian enlargement. Symptoms include acute abdominal pain (stabbing (70%), sudden and sharp (59%), radiate to the back, flank or groin (51%)), nausea and vomiting (70%), peritoneal signs (3%), and age under 50 yr in 80%. Signs are those of an acute abdomen and cervical motion tenderness when the torted side is put on stretch. Investigations include CBC (fall in Hgb with hemorrhage and an increase in WBC with necrosis), electrolytes (especially if there has been persistent vomiting), ultrasound. In children a torted ovary may be normal. In adults a torted ovary may have a large cyst (up to 80%). With time the ovary enlarges and may be solid (hyperechoic) or fluid filled (hypoechoic). Free intraperitoneal fluid in the pelvis results from lymphatic and venous congestion or infarction with intraperitoneal hemorrhage. Intra-ovarian artery flow usually reflects partial torsion resulting from extrinsic compression and occlusion of the ovarian vein with an intact arterial supply. Blood flow usually indicates a viable ovary. Doppler ultrasound will document arterial flow. Detorsion can be used in young women to preserve ovarian function. 93% of detorted ovaries will regain normal ovarian function. Salpingo-oophorectomy should be completed if there is a concern of malignancy or if the tissue is clearly gangrenous. There is a 10% risk of recurrent torsion. Methods to prevent this include oral contraceptives to decrease development of ovarian cysts. Ovariopexy fixes the ovary to the uterus or pelvic sidewall. Ovariopexy is preferred if the problem is seen in childhood.

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Studentsâ&#x20AC;&#x2122; Association - Macedonia 1st Summer School on Emergency Medicine 3.0 Hemorrhagic Ovarian Cyst Physiologic ovarian cysts from corpus luteal or follicular origin can become hemorrhagic. The woman may present with acute pelvic pain or a dull constant lower abdominal pain. If you take a menstrual history, she will likely be at the time of ovulation. Rupture of a blood-filled corpus luteum cyst usually gives abdominal pain with guarding and possibly rebound. There is diffuse pelvic tenderness on vaginal exam. The pain is more pronounced on the side of the ovarian cyst. A mass may or may not be palpated. If the hemorrhage is severe, then the abdominal is distended and there can be hypovolemic shock. Ultrasound may show a heterogeneous, hypoechoic mass with internal echoes, thin and thick septations, fluid debris level, echogenic retracting clot or irregular nodular wall. Acute intracystic hemorrhage may appear isoechoic to the ovarian stroma and mimic an enlarged ovary. There will be free fluid in the cul de sac and sometimes in the upper abdomen. A Ă&#x;HCG or urine pregnancy test is negative. Culdocentesis will reveal free blood in the abdomen. When there is significant hemorrhage, a laparotomy is indicated to confirm the diagnosis and excise the cyst. The ovarian defect should be closed in layers with fine absorbable suture. Laparoscopy could be considered in a hemodynamically stable patient, however, it is often difficult to see well in the presence of a significant amount of intra-abdominal blood. 4 Summary Gynecologic emergencies involve assessment by history and physical examination including a pelvic examination while one is also carrying out the important resuscitation principles of assessing and maintaining an airway, breathing and circulation. The resuscitation efforts of accessing the venous system and ensuring appropriate fluid infusion can be done while sending off lab work and organizing other investigations appropriate to the situation. The expediency with which all of these maneuvers need to take place depends on the severity of the patientâ&#x20AC;&#x2122;s presentation. A surgical intervention may be required, so NPO is important along with an assessment of the urinary output. Where possible, it is important to explain the situation to the patient and family and obtain informed consent. Psychosocial and possible legal consequences of the precipitating problem will need to be addressed once the acute issue is effectively managed and the patient is medically stable.

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Studentsâ&#x20AC;&#x2122; Association - Macedonia 1st Summer School on Emergency Medicine DRUG POISONING Introduction Poisoning can result from an overdose of either prescribed drugs or drugs that are bought over the counter. It can also be caused by drug abuse or drug interaction. The effects vary depending on the type of drug and how it is taken (see table below). When you call the emergency services, give as much information as possible. While waiting for help to arrive, look for containers that might help you to identify the drug. Recognition features Category

Drug

Painkillers

Asprin (swallowed)

Upper abdominal pain. Nausea & vomiting. Ringing in the ears. "Sighing" when breathing. Confusion and delirium. Dizziness.

Paracetamol (swallowed)

Little effect at first, but abdominal pain, nausea and vomiting may develop. Irreversible liver damage may occur within 3 days (malnourishment and alcohol increase the risk).

Effects of poisoning

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Studentsâ&#x20AC;&#x2122; Association - Macedonia 1st Summer School on Emergency Medicine Category

Drug

Nervous system depressants and tranquillizers

Barbiturates and benzodiazepines (swallowed)

Lethargy and sleepiness, leading to unconsciousness. Shallow breathing. Weak, irregular, or abnormally slow or fast pulse.

Stimulants Amphetamines and (including hallucinogens Ecstasy) and LSD(swallowed); cocaine (inhaled)

Excitable, hyperactive behavior, wildness and frenzy. Sweating. Tremor of the hands. Hallucinations.

Narcotics

Morphine, heroin (commonly injected)

Small pupils. Sluggishness and confusion, possibly leading to unconsciousness. Slow, shallow breathing which may stop altogether. Needle marks, which may be infected.

Solvents

Glue, lighter fuel (inhaled)

Nausea and vomiting. Headaches. Hallucinations. Possibly, unconsciousness. Rarely, cardiac arrest.

Effects of poisoning

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Studentsâ&#x20AC;&#x2122; Association - Macedonia 1st Summer School on Emergency Medicine Treatment Your aims: To maintain breathing and circulation. To arrange removal to hospital. If the casualty is conscious: Help them into a comfortable position. Ask them what they have taken. Reassure them while you talk to them. Dial 999 for an ambulance. Monitor and record vital signs - level of response, pulse and breathing - until medical help arrives. Look for evidence that might help to identify the drug, such as empty containers. Give these samples and containers to the paramedic or ambulance crew. If the casualty becomes unconscious: Open the airway and check breathing. Be prepared to give chest compressions and rescue breaths if necessary. Place them into the recovery position if the casualty is unconscious but breathing normally. Dial 999 for an ambulance. DO NOT induce vomiting.

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Students’ Association - Macedonia 1st Summer School on Emergency Medicine ACUTE CORONARY SYNDROME 1.1 Definition of Acute Coronary Syndromes 1.2 The definition of acute coronary syndrome depends on the specific characteristics of each element of the triad of clinical presentation (including a history of coronary artery disease), electrocardiographic changes and biochemical cardiac markers. An acute coronary syndrome may occasionally occur in the absence of electrocardiographic changes or elevations in biochemical markers, when the diagnosis is supported by the presence of prior documented coronary artery disease or subsequent confirmatory investigations. The immediate management of a patient with an acute coronary syndrome is determined by the characteristics of the presenting electrocardiogram and, in particular, the presence or absence of ST segment elevation. In combination with the clinical presentation, an ST segment elevation acute coronary syndrome is defined by the presence of ≥1 mm ST elevation in at least two adjacent limb leads, ≥2 mm ST elevation in at least two contiguous primordial leads, or new onset bundle branch block. In the absence of ST segment elevation (non-ST segment elevation acute coronary syndrome), patients are initially managed without emergency reperfusion therapy. Acute coronary syndromes The main diagnostic categories of acute coronary syndrome, unstable angina and myocardial infarction, are defined by the serum concentration of cardiac enzymes and markers. The cardiac markers, troponin T and troponin I, are extremely sensitive to myocardial injury and damage. Minimal damage can be detected, allowing identification of ‘micro-infarcts’ where there is an elevation in the troponin concentration without a significant rise in creatine kinase or other cardiac enzymes. One consequence of the use of troponin measurement has been a blurring of the distinction between unstable angina and myocardial infarction. The European Society of Cardiology (ESC) and American College of Cardiology (ACC) state that any elevation, however small, of a troponin or the creatine kinase MB (muscle, brain) isoenzyme is evidence of myocardial necrosis and that the patient should be classified as having myocardial infarction, however small.3,4 The global registry of acute coronary events (GRACE) uses these diagnostic criteria for acute myocardial infarction and unstable angina. This has categorized many patients with very small

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Students’ Association - Macedonia 1st Summer School on Emergency Medicine rises in troponin concentrations as having sustained a myocardial infarction despite the absence of major tissue damage. Modest rises in troponin concentration are associated with a substantial increase in the risk of death and patients with modest troponin rises have a similar one and six month mortality to those sustaining a major clinical myocardial infarction Since the introduction of troponin measurement and the new ESC and ACC guidelines, many studies have used this changed definition of acute myocardial infarction. In order to synthesize the evidence on treatment of acute myocardial infarction from before and since this change, the British Cardiac Society (BCS) working group definition of myocardial infarction has been used throughout the guideline. The BCS definition has three categories for acute coronary syndromes, with a threshold of serum troponin concentration above which a clinical myocardial infarction is diagnosed. This approximates to the previous World Health Organization (WHO) definition of myocardial infarction. Patients with a troponin concentration below this threshold but above the reference range are designated as having an acute coronary syndrome with evidence of myocyte necrosis . There are no international standards for the measurement of troponin T or I. It has been agreed that the functional detection limit of any assay should be set at the concentration above which the inter-assay imprecision has a coefficient of variation (CV) ≤ 10% and that a “positive” troponin result for either troponin T or I is any value greater than the 99th centile for the local reference population. A degree of confusion has arisen around the terminology for ACS. Early therapeutic intervention is guided by results of initial investigations, such as the presence or absence of ST segment change, with later management and discharge diagnosis determined by the results of subsequent investigations and ACS category. 2 Presentation, assessment and diagnosis 2.1 Clinical Presentation and immediate assessment A high quality systematic review of 21 studies examined the usefulness of 16 different clinical signs and symptoms in the diagnosis of acute coronary syndromes. Taken in isolation, no single sign or symptom was discriminatory. A systematic review by the Agency for Health Care found that symptom characteristics were also unhelpful as prognostic factors. The current American Heart Association/American College of Cardiology (AHA/ACC) guidelines recommend that five factors should be considered together when assessing the likelihood of myocardial

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Studentsâ&#x20AC;&#x2122; Association - Macedonia 1st Summer School on Emergency Medicine ischemia relating to acute coronary syndromes. These are the nature of the symptoms, history of ischemic heart disease, sex, increasing age, and the number of traditional cardiovascular risk factors present. High risk features include worsening angina, prolonged pain (>20 minutes), pulmonary edema, hypotension and arrhythmias. The diagnosis and management of a patient with suspected acute coronary syndrome requires a detailed clinical assessment and the recording of a 12 lead electrocardiogram. Many treatments, especially for ST elevation acute coronary syndrome, are critically time dependent and the immediate clinical assessment of all patients with a suspected acute coronary syndrome is essential. The indications for reperfusion therapy are based primarily upon the metaanalysis of the Fibrinolytic Therapy rialistsâ&#x20AC;&#x2122; Collaboration (FTTC) group. They reported that electrocardiographic predictors of mortality benefit from fibrinolytic therapy were the presence of ST segment elevation or new onset bundle branch block. The FTTC group did not distinguish between left and right bundle branch block although several guidelines and trials specifically stipulate left bundle branch block only. Registry data of acute myocardial infarction show that right bundle branch block is as common as, and has a higher mortality than, left bundle branch block. The majority of patients presenting with acute myocardial infarction and right bundle branch block have associated ST segment elevation. It is unknown whether patients with acute myocardial infarction presenting with right bundle branch block in the absence of ST segment elevation will derive benefit from reperfusion therapy. No specific evidence was identified on when to record serial electrocardiograms or on which patients they should be carried out. Patients with suspected acute coronary syndrome should be assessed immediately by an appropriate healthcare professional and a 12 lead electrocardiogram should be performed. -

Repeat 12 lead electrocardiograms should be performed if there is diagnostic uncertainty or a change in the clinical status of the patient, and at hospital discharge. Patients with persisting bundle branch block or ST segment change should be given a copy of their electrocardiogram to assist their future clinical management should they represent with a suspected acute coronary syndrome.

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Studentsâ&#x20AC;&#x2122; Association - Macedonia 1st Summer School on Emergency Medicine Continuous ST segment monitoring, additional lead monitoring and vector cardiography appear to yield valuable long term prognostic information, but their role in the assessment and diagnosis of acute coronary syndrome has yet to be established. 2 PRESENTATION, ASSESSMENT AND DIAGNOSIS 2.1.1

SELF MEDICATION IN PATIENTS WITH CORONARY ARTERY DISEASE

In patients with known coronary heart disease, self medication with glyceryl trinitrate provides rapid symptom relief of anginal pain, but its effect lasts for less than 60 minutes. Patients with known coronary heart disease should be given clear advice on how to self medicate with glyceryl trinitrate to relieve the symptoms of their angina: an initial dose should be taken at symptom onset if necessary, a further two doses should be taken at five minute intervals if symptoms have not settled within five minutes of taking the third dose (15 minutes in total from onset of symptoms) emergency medical services should be contacted. 2.2 Biochemical Diagnosis in acs The measurements of troponin I and T are of equal clinical value.28 There is a large and consistent body of evidence that the optimum time to measure troponin (I or T) for diagnosis or prognostic risk stratification is 12 hours from the onset of symptoms. Where there is uncertainty around time of symptom onset, troponin should be measured 12 hours from presentation. In patients with an acute coronary syndrome who present to the emergency department within six hours of pain onset, around half will have an elevated troponin I on admission. Systematic review of troponin measurement <12 hours from symptom onset suggests that management and treatment decisions can be aided by the earlier measurement of troponin and repeated testing is often appropriate. Increased troponin concentration provides one measure of risk that should not be relied upon in isolation. For example, patients with unstable angina and a troponin concentration within the reference range at 12 hours, can have a high risk of future cardiovascular events (30 day risk of death up to 4-5%). In addition, an elevated troponin concentration cannot diagnose an acute coronary syndrome in isolation. Elevated troponin concentrations can occur in patients without an acute coronary syndrome and are associated with adverse

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Studentsâ&#x20AC;&#x2122; Association - Macedonia 1st Summer School on Emergency Medicine outcomes in many clinical scenarios including patients with congestive heart failure, sepsis, acute pulmonary embolism and chronic renal failure. In patients with suspected acute coronary syndrome, serum troponin concentration should be measured on arrival at hospital to guide appropriate management and treatment. To establish a diagnosis in patients with an acute coronary syndrome, a serum troponin concentration should be measured 12 hours from the onset of symptoms. Patients with an acute coronary syndrome should be managed within a specialist cardiology service. -

Patients with an acute coronary syndrome should have continuous cardiac rhythm monitoring. Oxygen therapy should be administered to patients with hypoxia, pulmonary edema or continuing myocardial ischemia. Patients with an acute coronary syndrome should be treated immediately with aspirin (300 mg). In the absence of bradicardia or hypotension, patients with an acute coronary syndrome in Killip class I should be considered for immediate intravenous and oral beta blockade. Patients with clinical myocardial infarction and diabetes mellitus or marked hyperglycemia (>11.0 mmol/l) should have immediate intensive blood glucose control. This should be continued for at least 24 hours.

3. Post-initial management -

Patients with an ST elevation acute coronary syndrome should be treated immediately with primary percutaneous coronary intervention. Patients undergoing primary percutaneous coronary intervention should be treated with a glycoprotein IIb/IIIa receptor antagonist. Intracoronary stent implantation should be used in patients undergoing primary percutaneous coronary intervention. When primary percutaneous coronary intervention cannot be provided within minutes of diagnosis, patients with an ST elevation acute coronary syndrome should receive immediate thrombolytic therapy.

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Students’ Association - Macedonia 1st Summer School on Emergency Medicine Skills and Knowledge on Overdose Prevention (SKOOP) Prof.d-r.Daniela Chaparoska, University Clinic of Toxicology, Medical Faculty, Skopje, Macedonia

Goals To increase knowledge and understanding of the definition, causes and risk factors of overdose To explore and develop strategies for prevention of overdose To develop protocols for intervention when overdose occurs to minimize fatalities To promote provide and community responsibility for overdose prevention Definition of a Drug A common definition of the word ‘drug’ is any substance that in small amounts produces significant changes in the body, mind or both.” Definition of Drug Overdose of

An overdose occurs when an individual takes more of a drug or combination drugs than the body can handle.

In particular, overdose occurs when certain vital organs get overwhelmed, including: Lungs, heart, liver, kidneys and brain Why Overdose Happens? Quality of the drugs

Slow responses

Quantity of the drug or drugs

Under the influence

Mode of administration

Policy factors

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

Scope the Problem About 2% of heroin users die each year- many from heroin overdose 2002-09: 19 deaths in Macedonia 2009: most common cause of death men age 25-29 in Skopje or and several other cities These numbers clearly represent only a portion of actual deaths related to Overdose.

Death by overdose can Be Prevented!   

The symptoms of overdose CAN BE FATAL without intervention! The RESPONSE to an OVERDOSE is critical! Overdose death CAN BE PREVENTED!

Who’s At Risk?     

Anyone who uses drugs has the potential to overdose Any period of abstinence 90-day relapse curve Completion of residential treatment Release from prison or jail

Other Risk Factors    

Anticipation or occurrence of, any major life transition Major disappointment Reuniting with family with history of conflicts Holidays

Bio-Psycho-Social Risk Factors       

Physical health Weight Mental health Self-esteem Social isolation Unstable housing and living conditions Drinking problems

European Medical Students’ Association - Macedonia 1st Summer School on Emergency Medicine Many opioid overdoses are preventable!

Get the SKOOP! Signs of an Opiate Overdose          

Passing out unconscious Awake but unable to talk Slow breathing (less than 12 breaths per minute) Choking or gurgling sounds Limp Body Pale complexion Cold, clammy skin Turning blue (fingers and lips turn blue first) Vomiting Slow heartbeat/pulse

Who overdoses? Most often dependent long term users with 5- 10 years of experience rather than new users- about 17% occur among new users Definition of Psychoactive Drugs Psychoactive drugs affect mood, perception and/or thought, producing changes in both mind and body” Classification of Psychoactive Drugs        

Stimulants Sedative-Hypnotics Depressants Hallucinogens Enactogenes (XTC) “Club Drugs” (GHB; Special K) Other designer drugs Narcotics/Opiates

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Students’ Association - Macedonia 1st Summer School on Emergency Medicine Understanding Opiates   

Come from the poppy or are chemically created Taking too much results in OD-stopped breathing Different concentrations, strengths, durations of action

Opiates: Duration of Action       

Fentanyl Oxycontin Heroin Dilaudid Codeine Methadone Demerol

24 hours 12 hours 6-8 hours 4-6 hours 3-4 hours 2-4 hours 1-2 hours

Prevention    

Assessment of risk Dialogue with at-risk users or those with a history of use Get people thinking about their use Education: OD prevention tips

OD Prevention Tips    

Mixing drugs increases likelihood of OD if you are going to drink alcohol and use heroin, use the heroin first Take the drug in a way that gets you high slower Do a tester shot Keep track of how much you are using

More Prevention Tips   

Learn your tolerance Use the same dealer whenever possible Use the people you know and trust

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Students’ Association - Macedonia 1st Summer School on Emergency Medicine   

If you must use alone, ask people to check in or consider calling a friend Locking the door makes it harder for help to reach you Consider your surroundings

More Prevention Tips      

Use less when you are ill or while you recovering from the illnes Be aware of power dynamics with partners Learn to hit yourself Learn abaut drug pharmacology Think through each step of your drug taking Make an overdose plan!

Dispelling Myths   

“Old timers” don’t OD In fact-in many cases, it is ‘OLD-TIMERS’ who DO Non-injectors can’t OD

Physiology  

Generally happens over course of 1-3 hours- the stereotype “needle in the arm” death is only about 15% Opioids repress the urge to breath – decrease response to carbon dioxide leading to respiratory depression and death

SKOOP Model  

Each exchange selects staff and peers to become trainers: interest outweighs formal education in success of trainer Physician offers support and oversight as well as prescribing and dispensing naloxone

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Students’ Association - Macedonia 1st Summer School on Emergency Medicine Key risk factor: Lowered tolerance  

Tolerance- repeated use of a substance may lead to the need for increased amounts to product the same effect Abstinence decreases tolerance increasing overdose risk  Incarceration  Hospitalization  Drug treatment/detox

Key risk factor: Mixing drugs  

Using an opioid with other depressants such as alcohol or benzodiazepines raises the risk Cocaine is a stimulant but:  High doses also reduce the respiratory drive  Wears off sooner than heroin in a speedball  Involved in about 38%

Other risk factors    

Major illness Changes in the quality of the heroin: fentanyl Depression Overdoses seem to come in clusters- if someone has had a recent overdose pay attention

Messages for overdose responders Try to use with others who know what to do if an overdose happens Be careful using alone especially if  

Using after abstinence Mixing different classes of drugs

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Students’ Association - Macedonia 1st Summer School on Emergency Medicine Watch out for your friends, particularly under risky circumstances Opioid maintenance as prevention  

Methadone maintenance may decrease the risk of overdose by up to 75% Since the institution of buprenorphine and methadone maintenance in 1996 in France heroin overdose has dropped by 79%

Opioid maintenance  

Methadone and buprenorphine act to keep tolerance up- harder to get high but harder to overdose Both may increase risk of overdosing on other depressants if taken in high doses

Recognition    

Overdose rarely immediate- be aware of companions all the time when using Nodding versus unresponsive Blue lips and nail beds Slow breathing, gurgling

Act: Call name, sternal rub: rub knuckles hard up and down breast bone Response  Call192- “My friend is unconscious/not breathing” Give location. No need to say heroin overdose 

Police may come

Rescue breathing

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Students’ Association - Macedonia 1st Summer School on Emergency Medicine

Teach mouth to mouth using a dummy for practicing. If you must leave the overdose even for a few minutes put them into the recovery position so they won’t choke on vomit.

Recovery Position

Rescue Breathing  



Clear the Airway/Perform Rescue Breathing Rescue breathing is one of the most important steps in preventing an overdose death. If you are performing rescue breathing, you are getting much needed air into someone’s body who will die without it. It’s important that the person’s airway is clear so air can get into their lungs. Place the person on their back, place your hand under their neck and tilt their chin up. Check to see if there is anything in their mouth blocking their airway, such as gum. If so, stick your fingers in their mouth and remove it. Use the head-tilt-chin-lift method to open the airway

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Students’ Association - Macedonia 1st Summer School on Emergency Medicine           

Tilt the head back with nearest hand by applying backward pressure to the forehead. Place other hand under chin bone and lift Tilt head back without closing mouth and check for breathing (ear to mouth). pinch the nose to prevent air coming out of nose Take a deep breath and put your mouth over theirs Establish a tight mouth-to-mouth seal Give 2 slow breaths. Blow enough air into their lungs to make their chest rise. Turn your head after each breath to ensure the chest is rising and falling. If it doesn’t work, tilt the head back more. Breathe again. Count one-one thousand, two-one thousand, three one thousand, and four one thousand. Breathe again.

Evaluate the Situation     

Has the persons begun to breathe again on their own? Are they conscious now? Can they communicate with you? Continue to assess them and monitor their breathing. If they are still unconscious and not breathing….

Recovery Position

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Students’ Association - Macedonia 1st Summer School on Emergency Medicine Naloxone (Narcan)     

Opioid antagonist which reverses opioid related sedation and respiratory depression and may cause withdrawal Displaces opioids from the receptors, then occupies the receptor for 30-90 minutes No psychoactive effects Over the counter in Italy Routinely used by EMS

Administration    

Inject into muscle but subcutaneous and intravenous are fine also Acts in 2-8 minutes If no response in 2-5 minutes repeat Lasts 30-90 minutes

Potential Harm? 



Sinking back into overdose when it wears off  Study of 998 OD patients who were administered naloxone by EMS and refused to go to the hospital- none died in the next 12 hours Using more heroin- naloxone as safety net  Risks unpleasant abrupt withdrawal

Side effects- in opioid user Common: Confusion, headache, nausea and vomiting, aggressiveness Uncommon or rare: Seizures, pulmonary edema- possibly from the lack of oxygen not the reversal of overdose

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Students’ Association - Macedonia 1st Summer School on Emergency Medicine Harm Reduction 

Emergency Medical Services give 1.2- 1.6 milligrams of naloxone which precipitates severe withdrawal in the dependent person 

Overdose prevention services recommend starting with 0.4 with an additional dose readily available

Results: awake and breathing Narcan wears off in 30-90 minutes  

Don’t leave the overdoser alone as sedation may return Reassure the overdoser if s/he is drug sick- the naloxone will wear off- don’t use more heroin to feel better!!

Conclusions   

Overdose prevention training consists of a few basic components Drug users can prevent and reduce overdoses Potential goals:  Overdose training as standard of care  Naloxone over-the-counter

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Studentsâ&#x20AC;&#x2122; Association - Macedonia 1st Summer School on Emergency Medicine

Workshop Investigating Cardiological Case Case presentation A 47 year old gentleman presented to his general practitioner with acute onset lower back pain. The pain had commenced during coitus and radiated down the right leg. The initial diagnosis was of acute disc prolapse and he was referred for an urgent neurosurgical opinion. The neurosurgeon concurred that the pain may well have been of neurological origin and arranged an MRI scan. This was reported as showing no evidence of spinal cord pathology. The patient was reassured with the results of the MRI findings and was advised the pain was probably musculoskeletal in origin and should settle. Over the subsequent 6 weeks, the pain persisted and indeed increased in severity. The patient noted claudication-type pain in his right leg after approximately 100 metres. As the pain had not resolved after 6 weeks he revisited his general practitioner. During the subsequent examination the pulses in his right leg were noted to be absent and he was referred for an urgent vascular surgical opinion. The patient was seen the following day in the vascular clinic where a history of severe acute claudication-type pain was noted in the right leg. There was a past medical history of marked hypertension and hyperlipidaemia, for which he took relevant medications, but none of angina, myocardial infarct or valvular heart disease. On clinical examination the heart rate was 68 beats per minute regular. The blood pressure in the right arm 130/70 mmHg was lower than that of the left arm 160/80. Cardiac examination was normal. There was no clinical evidence of an abdominal aortic aneurysm. Examination of the limbs revealed that the right lower limb pulses were all absent whilst those of the left leg were present and of good volume. An urgent abdominal ultrasound scan was arranged which demonstrated dissection of the intra-abdominal aorta and a subsequent CT scan confirmed that the dissection was a Type A dissection extending from the aortic valve down to the aortic bifurcation. A dissection flap was identified in the ascending aorta and also in the postero-inferior aspect of the descending aorta. Both lumens were noted to have flow within them with the true lumen supplying the celiac axis, superior mesenteric artery and right renal artery and the false lumen supplying the left renal artery and

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Studentsâ&#x20AC;&#x2122; Association - Macedonia 1st Summer School on Emergency Medicine inferior mesenteric artery. Immediately below the inferior mesenteric artery the false lumen obliterated. Keywords: ________________________________________________ ________________________________________________ What is the most likely cause ? ________________________________________________ What investigations would you suggest? ________________________________________________ What would you tell the patient at this stage? ________________________________________________ Discussion! Conclusion ________________________________________________ ________________________________________________ ________________________________________________

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Students’ Association - Macedonia 1st Summer School on Emergency Medicine NEUROLOGICAL CASE 21- year old patient, accepted in the Emergency Center of surgery. Out of the anamnesis taken we have a data of loss of conscience after a fall from the house stairs. The patient doesn’t remember the event, and he suffers of vomiting drives 1 hour after the fall, when he has come to the hospital. The immediate examination shows that the patient is in good conscience, and the vital functions are normal. The registered arterial blood tension is 120/80 mmHg, pulse – 86 bits/min; the breathing is regular, normal, with 18 respirations/min. There are not neurological deficits noticed, and the RTG of the cranium is regular. 8 hours after the examination, the patient, who was sent to home treatment, is coming back to the hospital on another examination. Now he is somnolent, with positive Babinski-reflex on the right side. The arterial blood tension now is 150/80 mmHg, the breathing is lightly burst with 22 respirations/min. There is no febrile condition, and the laboratory analyses are normal. The patient is non-smoker, doesn’t consume alcohol, and there is no data of neurological problems in his close family and relatives. What happens next?

Keywords: ________________________________________________ ________________________________________________ What is the most likely cause ? ________________________________________________ What investigations would you suggest? ________________________________________________

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia

European Medical Studentsâ&#x20AC;&#x2122; Association - Macedonia 1st Summer School on Emergency Medicine What would you tell the patient at this stage? ________________________________________________ Discussion! Conclusion ________________________________________________ ________________________________________________ ________________________________________________

The 1st Summer School on Emergency Medicine 27.06-01.07.2010 Ohrid, Macedonia