• No results found

IS THERE A DOCTOR IN THE HOUSE?

N/A
N/A
Protected

Academic year: 2021

Share "IS THERE A DOCTOR IN THE HOUSE?"

Copied!
62
0
0

Loading.... (view fulltext now)

Full text

(1)

IS THERE A DOCTOR IN THE

HOUSE?

FAMILY MEDICINE WINTER REFRESHER

COURSE

FEBRUARY 4, 2016

Matthew Tews, DO, MS John Ray, MD

Kathleen Williams, MD Bradley Burmeister, MD

(2)

Real Life...

• You witness a gentleman become unresponsive at the gym

• You are the first on the scene of a car accident

• You are on an airplane and the stewardess asks for a doctor

• There is an explosion nearby and you arrive on the scene before anyone else

(3)

Objectives

• Describe an approach to an acutely ill or injured patient • Discuss updates to basic life support

• Identify steps to take when arriving at the scene of a car accident

• Explain how you can best provide assistance to a patient on an airplane in flight

(4)

APPROACHING THE

ACUTELY ILL OR

INJURED PATIENT

(5)
(6)

The Approach

• Stay Calm • Stay Alert

• Stay Organized

• Remember Your Alphabet

(7)

Stay Calm

• Take a few seconds to collect yourself • Encouraging points

• You DON’T have to figure it all out

• You’re goal is to identify potential problems and treat emergencies

• You DON’T have to definitely manage every complaint

• Focus on identifying what needs to be done now

• You CAN and SHOULD get help – call 911!

(8)

Stay Alert

• Be aware of your surroundings

• Make sure the scene is safe! • Two victims are worse than one

• Identify your resources

• Bystanders (CPR trained?)

• Is there a defibrillator available? • First Aid kit?

(9)

Stay Organized

• Evaluate for life-threatening processes

• A: Airway

• Is it open? Are they moving air? Can they speak? Is it at risk for closing (stridor, muffled voice, throat swelling)?

• B: Breathing

• Wheezing? Equal breath sounds?

• C: Circulation

• Can you feel a pulse? Is it fast? Signs of good perfusion?

• D: Disability

• Are they alert? Do they response to pain? Are they moving limbs?

• E: Exposure

(10)
(11)

Stay Focused

• Focus on the problem

• Identify the patient has a breathing problem and go from there

• Think AMPLE: • A: Allergies • M: Medications • P: Past History • L: Last meal • E: Events

(12)

PUBLIC MEDICAL

EMERGENCIES

(13)
(14)

Common Medical Emergencies

• What do you do in the case of:

• Anaphylaxis • Seizure • Overdose • Hypoglycemia • Stroke • Myocardial infarction • Cardiac arrest

(15)

Basic Life Support Principles

• Immediate recognition of cardiac arrest • Activation of emergency response system • Early CPR

(16)

Adult BLS and CPR Updates

• The recommended sequence for a single rescuer has been

confirmed: the single rescuer is to initiate chest compressions before giving rescue breaths (C-A-B rather than A-B-C) to

reduce delay to first compression.

• There is continued emphasis on the characteristics of

high-quality CPR:

• Compressing the chest at an adequate rate and depth • Allowing complete chest recoil after each compression • Minimizing interruptions in compressions

• Avoiding excessive ventilation

• The recommended chest compression rate is 100 to 120/min

(updated from at least 100/min).

• The clarified recommendation for chest compression depth for

adults is at least 2 inches (5 cm) but not greater than 2.4 inches (6 cm).

• Bystander-administered naloxone may be considered for

(17)
(18)
(19)

Pediatric BLS Updates

• Reaffirming the C-A-B sequence as the preferred sequence for pediatric CPR

• New algorithms for 1-rescuer and multiple-rescuer pediatric HCP CPR in the cell phone era

• Establishing an upper limit of 6 cm for chest compression depth in an adolescent

• Mirroring the adult BLS recommended chest compression rate of 100 to 120/min

• Strongly reaffirming that compressions and ventilation are needed for pediatric BLS

(20)
(21)

Opioid Overdose

IM or IN naloxone

• Unresponsive, no breathing, + pulse

• Not cardiac arrest

• 2014 – naloxone

autoinjectors approved by USFDA for lay

rescuers and HCP’s • MMWR Report, 6/2015

• Increasing number of clinics and pharmacies providing kits to laypersons

(22)

EXERCISE #1

Public Medical Emergencies

(23)

CAR ACCIDENT

SCENES

(24)
(25)

Initial Actions

• Call 911

• Approach the scene carefully

• Be careful where you park • Turn on hazards

• Watch for debris

• Turn off the ignition

• Tell the victim not to move – don’t move them

• Do not pull someone from a car wreck if they are not moving on

their own

(26)

Initial Actions

• If responsive, ask if they want assistance • Protect the victim until help arrives

• Cover victim with blanket or coat • Protect them from the elements

• Stabilize neck/spine • Medical interventions

• If unresponsive, check your ABC’s

• Only looking for life-threatening issues

(27)

Traumatic Arrest

• What do MVC victims die from?

• Head injury

• Spinal cord injury • Airway injury

• Chest injury

• Abdominal injury • Blood loss at scene

• When should you start CPR?

• Survival rate in traumatic cardiac arrest is low • Treat reversible causes

• What came first?

• Trauma or non-traumatic cardiac arrest?

(28)

Liability

• Wisconsin's Good Samaritan statute for emergency

medical care states the following:

Any person who renders emergency care at the scene of any

emergency or accident in good faith shall be immune from civil liability for his or her acts or omissions in rendering such emergency care. This immunity does not extend when employees trained in health care

or health care professionals render emergency care for compensation and within the scope of their usual and customary employment or

practice at a hospital or other institution equipped with hospital facilities, at the scene of any emergency or accident, enroute to a hospital or other institution equipped with hospital facilities or at a

(29)

Liability

• There are 3 requirements:

1) emergency care must be rendered at the scene of the emergency

2) the care rendered must be emergency care

3) any emergency care must be rendered in good faith.

The phrase "emergency care" refers to the initial evaluation and immediate assistance, treatment, and intervention rendered to the plaintiff during the period before care could

be transferred to professional medical personnel.

WI Stat § 895.48 (2012 through Act 45)

Clayton v. American Family Mutual Insurance Company, 2007 WI App 228, 305 Wis. 2d 766, 741 N.W.2d 297, 07-0051.

(30)

EXERCISE #2

Traumatic Emergencies

(31)

IN FLIGHT MEDICAL

EMERGENCIES

(32)
(33)

Background

Estimated incidence of reported in-flight medical emergencies is about 1 per 604 flights

(34)

Common Emergencies

• Chest pain • Syncope

• Asthma exacerbations • GI complaints

• "economy class syndrome,"

• A midair version of Virchow's triad: dehydration, immobilization, and

(35)

On Board Resources

• FAA regulations require all U.S. commercial airlines

weighing 7,500 pounds or more and serviced by at least one flight attendant to carry a defibrillator and enhanced emergency medical kit

• Flight attendants must be certified in CPR, including the use of an AED, every 2 years

• Pilots must also be trained in the use of the AED • Enhanced Emergency Medical Kits

(36)
(37)

Air Carrier Access Act of 1998

• Limited protection and guidance for physicians and other medical professionals who volunteer their services during flight

• Must be "medically qualified," render care in good faith, and receive no monetary compensation to be protected under this Act

(38)

• “An individual shall not be liable for damages in any action brought in a Federal or State court arising out of the acts or omissions of the individual in providing or attempting to provide assistance in the case of an in-flight medical

emergency unless the individual, while rendering such assistance, is guilty of gross negligence or willful

misconduct.”

• There are no documented cases of a physician being sued for providing assistance during an in-flight

emergency.

(39)

Disposition

• You don’t determine the ultimate disposition

• Work in conjunction with the airline’s medical team • You can always contact the ground medical team

• 15,000 in-flight emergencies found that the aircraft was diverted in only 7% of the cases

• Ultimately the decision to divert the plane lies with the pilot and the airline

• It takes at minimum 25 minutes to get from maximum altitude to being on the ground

(40)

In-Flight Advice

• Introduce yourself to the cabin crew and state your qualifications.

• Ask the patient for his or her permission before performing a thorough

history and physical exam.

• Use an interpreter if necessary.

• If the patient's condition is critical, request diversion to the nearest

appropriate airport.

• Cooperate with a medical response center and coordinate with airport

medical staff.

• Keep a written medical record of your patient encounter. • Perform only treatments you are qualified to administer.

(41)

EXERCISE #3

In Flight Emergencies

(42)

BASIC DISASTER

MEDICINE

(43)
(44)

Approaching a Blast Disaster

• Be safe – you don’t know what else might happen

• First responders are trained to do this – some more than others

• Don’t try to be a hero

• Help those who need immediate assistance • Wait for help to arrive

(45)

Blast Disaster Principles

• Types of blast injuries

• Primary – from blast wave • Secondary – from projectiles • Tertiary – from being displaced

(46)

Blast Disaster Principles

• Injuries to be concerned for:

• Lung

• Abdominal

• Ear – sign of other injuries • Amputation

(47)

Triaging Patients: Think SALT

Sort-Assess-Lifesaving Interventions-Treatment and/or Transport

• The only system compliant with CDC recommendations • Taught by NDLS and other national courses

(48)

SALT Triage

• Simple

• Easy to remember

• All Hazards and all types of patients

• Groups large numbers of patients together quickly • Applies rapid life-saving interventions early

(49)
(50)

Dead

Patient is not breathing after opening airway

• In Children, consider giving two rescue breaths • If still not breathing must tag as dead

Tag dead patients to prevent re-triage

Do not move

• Except to obtain access to live patients • Avoid destruction of evidence

(51)

Immediate

Serious injuries

Immediately life threatening

problems

High potential for survival

Examples

• Tension pneumothorax • Exposure to nerve agent

• Severe shortness of breath or seizures

(52)

Immediate

No to any of the following

C: Follows commands or makes purposeful movements?

R: Not in respiratory distress?

A: Hemorrhage is controlled? [controlled arterial bleeding]

P: Has a peripheral pulse?

(53)

Expectant

No to any of the following

C: Follows commands or makes purposeful movements?

R: Not in respiratory distress?

A: Hemorrhage is controlled? [Uncontrolled arterial bleeding]

P: Has a peripheral pulse?

(54)

Expectant

• DOES NOT MEAN DEAD!

• Important for preservation of resources

• Should receive comfort care or resuscitation when resources are

available

• Serious injuries

• Very poor survivability even with maximal care in hospital or

pre-hospital setting

• Examples

• 90% body surface area burn

(55)

Delayed

Serious injuries

• Require care but

management can be

delayed without increasing morbidity or mortality

Examples

• Long bone fractures • 40% BSA exposure to

Mustard gas

(56)

Delayed

Yes to all of the following

C: Follows commands or makes purposeful movements?

R: Not in respiratory distress?

A: Hemorrhage is controlled? [Uncontrolled arterial bleeding]

P: Has a peripheral pulse?

(57)

Minimal

Yes to all of the following

C: Follows commands or makes purposeful movements?

R: Not in respiratory distress?

A: Hemorrhage is controlled? [Uncontrolled arterial bleeding]

P: Has a peripheral pulse?

(58)

Minimal

• Injuries require minor care or no care • Examples

• Abrasions

• Minor lacerations

• Nerve agent exposure with mild runny

nose

(59)

After Patients are Categorized

• Prioritization process is dynamic

• Patient conditions change • Correct misses

(60)

EXERCISE #4

Blast Disaster Emergencies

(61)

EXERCISE #5

Putting it all together

(62)

References

• Centers for Disease Control. Blast Injuries: Fact Sheets for Professionals.

Available at:

http://www.nasemso.org/Projects/DomesticPreparedness/documents/CDC-Blast-Injury-Fact-Sheet.pdf

• Highlights of the 2015 AHA Guidelines Update for CPR and ECC. Available at:

https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/

• Lockey DJ, et al. Development of a simple algorithm to guide the effective

management of traumatic cardiac arrest. Resuscitation 84 (2013) 738–742

• Nable, et al. In-Flight Medical Emergencies during Commercial Travel. NEJM.

373;10. 2015

• Peterson, et al. Outcomes of Medical Emergencies on Commercial Airline Flights.

NEJM. 368;22. 2013.

• SALT Mass Casualty Triage. Disaster Medicine and Public Health Preparedness.

2008

• Thim T, et al. Initial Assessment and treatment with the Airway, Breathing,

Circulation, Disability, Exposure (ABCDE) approach. Int J Gen Med 2012; 5:117-121.

• Wheeler E, et al. Opioid Overdose Prevention Programs Providing Naloxone to

References

Related documents

With effect from the Appointed Date and upon the Scheme becoming effective, all permits including operating permits, quotas, rights, entitlements, licenses including those relating to

While replication [ 19 – 22 ] and cell division [ 23 – 26 ] are relatively well-studied processes in mycobacteria, chromosome segregation remains to be fully understood.

Generally, there are two primary legal approaches to internet contract enforcement: The United States model that relies on basic notice requirements to establish and

For the yielding limit state, the required minimum thickness of the base plate can be calculated as follows (AISC,2005d) = 0.65 as per Section 9.3 of ACI318-08.... The base plate

However, use or processing of the product not in accordance with the product's recommendations or not under ordinary conditions may affect the performance of the product and

Sense to chennai and allianz forgot number of bajaj allianz life home insurance policy is a duly filled surrender form to policy status through online on

Applied on concentric tube robots, the proposed algorithm fuses information extracted from monoplane fluoroscopic images, with the robot’s kinematics model, to achieve joint

Good leadership quality has been found to be related to increased psychological well-being and decreased sickness absence.[26] A recent study found that leaders that employ