How to manage Emergency Patient ? easy learning

In most of the emergency condition, at first we should try to save the life of patient. The Basic and most important factors to investigate immediately are : Airway, Breathing and Circulation. After maintaining these three vitals further medical procedure are operated in the patient.  Everybody including health professionals should keep the idea of proper management of emergency conditions.

1. Rapid Initial Survey (RIS)

a. Airway maintenance by Cervicalspine control.

b. Breathing and ventilation

c. Circulation (pulses and hemorrhage control)

d. Disability (neurological status)

e. Exposure (complete) and environment (temperature control)

f. restart sequence from beginning if patient deteriorates.

Note : We should always care for signs of shock.

A. AIRWAY  : first priority is to secure airway

• Chance of cervical spine injury in every trauma patient. immobilize with collar.

• Ability to breathe and speak should be assessed.

• ask patient a question; appropriate response indicates patient airway & ability to breathe.

• signs of obstruction are as following :

– agitation, confusion, “universal choking sign”, – respiratory distress, – unable to speak i.e. dysphonia, – adventitious sounds, – cyanosis.

• REASSESS FREQUENTLY (especially if patient status changes).

Airway Management : goals

– permit adequate oxygenation and ventilation

– facilitate ongoing patient management

– give drugs via endotracheal tube (ETT) if IV not available

• Note : start with basic management techniques before progressing to advanced

1. Basic Airway Management

• protect the C-spine

• head-tilt chin lift or jaw thrust (if C-spine injury suspected) to open the airway

• sweep and suction to clear mouth of foreign material

• nasopharyngeal airway

• oropharyngeal airway (not if gag present)

• transtracheal jet ventilation (through cricothyroid membrane) used as last resort, if unable to ventilate after using above techniques

2. Definitive Airway Management

• endotracheal intubation (ETI) with inline stabilization of spine.

– orotracheal ± Rapid Sequence Intubation (RSI).

– nasotracheal - may be better tolerated in conscious patient.

– does not provide 100% protection against aspiration.

– contraindicated with basal skull fracture.

• indications for intubation : – unable to protect airway and inadequate oxygenation via spontaneous ventilation (O₂ saturation < 90% with 100% O₂ or rising pCO₂)

– profound shock.

– anticipate in trauma, overdose, congestive heart failure (CHF), asthma, and

chronic obstructive pulmonary disease (COPD)

– anticipated transfer of critically ill patients surgical airway (if unable to intubate using oral/nasal route)

– needed for chemical paralysis of agitated patients for investigations

– cricothyroidotomy

B. BREATHING :

• LOOK mental status like : anxiety, agitation, colour, chest movement (bilateral or

asymmetrical), respiratory rate/effort, nasal flaring and Loss of consciousness.

• LISTEN sounds of obstruction like: stridor, breath sounds, symmetry of air entry, air escaping

• FEEL flow of air, tracheal shift, chest wall for crepitus, flail segments, sucking chest wounds, subcutaneous emphysema.

Breathing Assessment

• measurement of respiratory function: rate, pulse oximetry, ABG, A-a gradient, peak flow rate.

Management of Breathing

• treatment modalities:

–        nasal prongs,  simple face mask with oxygen reservoir,  CPAP/BiPAP

–        Venturi mask: used to precisely control O₂ delivery.

– Bag-Valve mask and CPAP: to supplement ventilation

C. CIRCULATION

Definition of Shock : inadequate oxygen perfusion to organ and tissues like: brain, kidney & extremities.

Clinical Evaluation :

• rapidly assess for cause of shock and clinical features of hemorrhage.

– early: tachypnea, tachycardia, narrow pulse pressure, reduced urine output, reduced capillary refill, cool extremities and reduced central venous pressure (CVP).

– late: hypotension and altered mental status.

Management of Hemorrhagic Shock

• secure airway and supply O₂

TREAT THE CAUSE OF THE SHOCK!

1. Control external bleeding.
2. Apply direct pressure.
3. Elevate profusely bleeding extremities if no obvious unstable fracture.
4. Consider vascular pressure points (brachial, axillary, femoral).
5. Do not remove impaled objects as they tamponade bleeding.
6. Tourniquet only as last resort.
7. Prompt surgical consultation for active internal bleeding.
8. Infusion of 1-2 L of NS or RL as rapidly as possible.
9. Replace lost blood volume at ratio of 3:1 (maintain intravascular volume)
10. If inadequate response, consider ongoing blood loss e.g. chest, abdomen, pelvis, extremities then operative intervention is required.

 Indications for blood transfusion :

–  Severe hypotension on arrival.

–  Shock persists following crystalloid infusion.

– Rapid bleeding.

–  Transfusion options with packed red blood cells (PRBCs).

– Cross-matched (ideal but takes time).

– Type-specific (provided by most blood banks within 10 min.).

–  Preferred to O-negative uncross-matched blood if both available.

–  O-negative (children and women of child-bearing age).

–  O-positive (everyone else) if no time for cross and match.

–  anticipate complications with massive transfusions.

# Transfusion options with fresh frozen plasma (FFP).

–        Used for clinical evidence of impaired hemostasis.

–        Ongoing hemorrhage and platelet count < 50,000, PT > 1.5 x normal range.

# vasopressors

–        Used if hypotension persists despite appropriate volume resuscitation

–        Dobutamine 2.0-20.0 mcg/kg/min for systolic BP over 100 mmHg

–        Dopamine 2.5-20.0 mcg/kg/min for systolic BP 70 to 100 mmHg

–        Norepinephrine 0.5-30.0 mcg/kg/min for systolic BP < 70 mmHg

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Haridra powder for fast wound healing

Wounds are commonly encountered. Though extremely common, without proper and timely intervention, they may get complicated leading to sepsis, septicaemia and scarring. Wounds are due to various types and intensity of physical injury wherein the skin is torn or punctured or a contusion is formed due to blunt force. Accordingly, a wound is called open when the skin is breached due to injury and closed when there is no tearing or cutting of skin. A wound is considered minor when it is superficial, away from natural orifices, with minor or no bleeding and not caused by a tool or instrument or animal.

Here, the term wound is confined to external and superficial injuries including incised wounds, lacerations, abrasions, puncture wounds, contusions and mild haematoma. If not severe and complicated, wounds can be successfully managed with simple traditional medical care making use of Haridra.

Haridra (Curcuma longa Linn.) :

Haridra is a well established medicinal plant of Indian medicine known for its wound healing properties. Classical medical literature is replete with the uses of turmeric and adequate evidence is available for its antiseptic, anti-inflammatory, anti-bacterial and anti-allergic properties. The earliest reference to turmeric with its indications for skin diseases and wounds is found in Ayurvedic text Charaka Samhita. Use of turmeric is recommended for facilitating wound healing in para-surgical procedures prescribed in Ayurveda such as leech therapy for chronic wounds and Kshara Sutra therapy for piles and fistula. Turmeric is the most common household medicine for first-hand management of injuries and wounds. Its juice, paste, powder, decoction and various formulations are used externally and internally. Haridra is dried rhizome, like that of ginger, of a perennial herb of Zingiberaceae plant family, which is extensively cultivated in all parts of India and harvested between October to April when the lower leaves of the plant turn yellow. The rhizomes are boiled and then dried and the skin peeled off. Turmeric is available in the market both in raw and powder forms. Powdered Haridra is an

essential commodity in Indian homes used as a condiment in almost all sorts of cooking.

Main chemical constituents : Curcuminoids including yellow colouring principal, curcumin, and an essential oil with high content of bisabolane derivatives.

Dosage form : Yellow-coloured fine powder, decoction, and paste.

Therapeutic properties : Haridra has anti-inflammatory, blood purifying, anti-allergic, antibacterial, anti-fungal, anti-protozoal, demulcent and wound-healing properties.

Dose and mode of administration : Haridra may be used simultaneously for washing the wound, application as paste on wound and orally in the following ways and dose schedule:

(1) For oral use the dose of turmeric powder for adults is 2 to 5 grams and for children it is 1 to 2 grams or juice of fresh turmeric in the dose of 10 to 20 millilitres for adults and 5 to 10 ml for children. It is administered twice daily with water

or honey.

(2) Wash the wound twice daily with turmeric decoction.

(3) Apply a thin paste of turmeric over the wound and keep it for 8 to 10 hours and then remove by gently washing the affected part with luke warm water. Alternatively, the wound is dressed with gauze soaked in turmeric decoction or juice or mixture of turmeric and mustard oil or honey. A new dressing should be used after cleansing the wound.

Indications and uses

(1) External and internal use of turmeric is indicated in acute and chronic wounds with not much damage to the tissues.

(2) Sepsis, allergic reaction, inflammation and skin discoloration around the wound are also manageable with oral use and topical application of turmeric.

Precautions and safety aspects :

(1) Due care must be taken to keep the wound clean and dry. It is advisable to use turmeric decoction for washing the wound.

(2) Frank bleeding and pus discharge from the wound should be attended to properly.

(3) Treatment with turmeric may be stopped if it does not yield beneficial effects in a couple of days.

(4) Being regularly used as a food item, turmeric is considered safe and no toxic or adverse effects are reported of its long-term use. However, its oral use in children and pregnant women should be done under medical supervision. It is safe for the

baby if a nursing mother is taking this medication.

(5) Persons receiving aspirin and warfarin should take turmeric with caution since their combination may cause bleeding.

(6) Side effects with turmeric may occur with use of more than the recommended doses. In that case, it may cause stomach upset

or other gastrointestinal problems such as diarrhoea.

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Ajamoda as Anti-toxin, Anti-oxidant & Joint pain reliever :

Ajamoda(Apium leptophyllum) consists of dried, aromatic fruits of Apium leptophyllum. It is an annual herb cultivated in the central and southern states of India and Nepal.

Ajamoda is a well-known drug for rheumatism, gout, cancer, obesity. It also acts as anti–toxin and anti-oxidant.

Main chemical constituents : Essential oil and fixed oil.

Dosage form : Aromatic, slightly bitter yellowish-brown powder giving a sensation of warmth to the tongue.

Therapeutic properties : Seeds have antiseptic, diuretic, anti-inflammatory, analgesic, anthelmintic, and anti-spasmodic properties.

Dose and mode of administration :

– The dose of the Ajmoda formulation for adults is 1 to 3 grams and for children 125 to 500 mg, two or three times a day, with warm water.

 – For local application as poultice, make a paste of the powdered seeds in warm water and apply on the affected joint.

Indications and uses :

(1) For relief from joint pain in arthritis such as osteoarthritis, rheumatoid arthritis, gouty arthritis, and non-specific arthritis.

(2) It is useful in dyspepsia and colic with or without joint pain, when taken with salt and warm water.

(3) Local application of the paste or poultice of Ajamoda seeds is recommended in painful joint condition.

Precautions and safety aspects

(1) Ajamoda powder should not be used during pregnancy and nursing mothers are advised to take it under medical supervision.

(2) The diuretic action of Ajamoda works by irritating the kidneys and therefore should be used with caution in cases of renal disorder.

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