PROVIDING PREHOSPITAL PROMPT MEDICAL CARE DURING THE MAIN

MEDICAL-SURGICAL EMERGENCIES

The Importance of Medical Emergencies in Family Medicine

- The family doctor as a first contact doctor has a very well-defined role in
determining the diagnosis in medical-surgical emergencies, in rapid assistance /
first aid assistance in order to save the patients life and in advising him
subsequently to go to hospital.
- In this sense, the FD has to intervene to uphold the patients vital functions in
due time.
- Therefore, the FD will apply cardiorespiratory resuscitation procedures in case
of cardiac arrest or collapse, he will tie a tourinquet in the case of an external
bleeding, he will apply a tampon in the nostrils in the case of a massive
epistaxis a or tracheostomy in cases of glottic edema causing asphyxia.

The Main Medical-Surgical Emergencies

- Cardiovascular : chest pain (angina), heart attack (myocardial infarction),

arrhythmia, hypertensive crisis, syncope ( fainting), near-syncope (lipothimie),
cardiac arrest.
- Respiratory : bronchitic asthma attack, acute pulmonary edema, pulmonary
tromboembolism, pneumothorax, haemoptysis, acute respiratory failure.
- Digestive: acute appendicitis, biliary colic, acute pancreatitis, melaena,
mesenteric infarction , acute peritonitis.
- Renal : renal colic, acute pyelonephritis, acute glomerulonephritis, acute urine
retention, acute renal failure.
- Neurological: sciatica crisis, vertiginous syndrome (vertigo), convulsions,
meningitis, coma;
- Gynaecological: ectopic pregnancy, abortion, eclamsia, genital bleeding
- Metabolical: dyspnea, hypoglycemia, tireotoxica crisis
- Dermatological: Erysipelas, Quinckes edema, rashes specific to infectious and
contagious diseases
- Ophthalmology: red eye, glaucoma crisis
- ENT: epistaxis, acute otitis, glottic edema
- Intoxications : carbon monoxide poisoning, organophosphorus poisoning,
alcohol intoxication, benzodiazepines, opiates intoxication
- Others: bleeding disorders, sepsis, burns, frostbite, trauma.
The FD will have to determine an initial diagnosis as sooner as possible
Therefore , in the case of a patient who exhibits pale teguments (skin), cold
extremities, a thready pulse, profuse cold sweating, polipnee, arterial hypotension ,
FD will indicate the diagnosis of shock.
By excluding other types of shock due to burns, traumas, sepsis FD will take into
account the hypovolemic shock.

Untill he establishes an etiological diagnosis and the hospitalization of the patient in a

specialized department the FD will have to alleviate rapidly the hypovolemia,
acidosis, hypoxia and maintain the pressure of perfusion in the tissues by applying a
saline infusion, sodium bicarbonate, glucose, oxygen and vasoconstrictors
(dopamine, dobutamine, norepinephrine).
The anaphylactic shock can occur in case of insect bites or intravenous
administration of some particular substances (penicilin) therefore the urgent
administration of adrenaline and hydrocortisone hemisuccinat is necessary.

In acute intoxications the FD will have to give immediately the adequate antidote to
the patient as , for example , atropine in pesticide poisoning (organophosphorus
compounds) and perform gastric lavage.

The family doctor is obliged to treat the patient untill the moment of his hospitalization
in a specialized department or untill the arrival of the ambulance which takes over the
patient .

To provide first aid in medical emergencies - MF must own a surgical emergency kit.

The emergency kit should contain:

- Equipment and materials = stethoscope, sphygmomanometer, syringes, cotton

wool, rubbing alcohol, tourniquet, splints, surgical needles, surgical thread, clamps,
EKG, alcohol, iodine, sterile compresses

- Drugs = nitroglycerin, Scobutil NO - SPA, glucose, diazepam, phenobarbital, Miofilin

frusemide hydrocortisone hemisuccinat
Algocalmin, adrenaline, etc..

- THE CARDIAC ARREST : It represents a clinical state after the cessation of

normal circulation of the blood due to failure of the heart to contract effectively.

The diagnosis of cardiac arrest is established after the following symptoms:

- sudden pallor or cyanosis
- absence of pulse in the large arteries (carotid or femoral)
- absence of heart sounds
- loss of consciousness (6-12 seconds after cessation of oxygen supply to the
brain)
- the sudden cessation of respiratory movements ( in the case of primary
circulatory arrest, after 15-40 seconds)
 - the appearance of fixed mydriasis, dilated pupils , non-reactive to light ( after 30
up to 90 seconds )

THE RESUSCITATION PROCEDURE IN CARDIOPULMONARY ARREST is done

in the first 3-5 minutes after the arrest, when the patient is in clinical death,
afterwards if hes not resuscitated he enters biological death the cessation of brain
functions when fixed midriasis , opaque cornea and cadaveric lividities ( livor mortis)
occur.

ABCD RULE

A Airways

The unobstruction of the respiratory ways;

The removal of foreign bodies from the oropharyngian region , the head must be
kept in hyperextension and the mandible will be held backwards with the chin pointig
upwards.

Toracic blows will be carried out against the back of the patient or abdominal
compression will be performed ( HEIMLICH manoeuvre) in the case of foreign bodies
aspiration. If the victim is unable to breathe, the doctor will position himself behind
her back and will place his fist with the thumb oriented towards the victims abdomen
above the navel and under the ribs and sternum aria.

He will grab his fist with the other hand and he will pull both hands 4 times upward
and inward very fast and with an amount of force.
This manoevre will increase the pressure in the abdomen, causing the pushing of
the diaphragm upward.
Consequently, the diaphragm will increase the air pressure in the lungs, and the
positive pressure will push the object from the trachea through the superior air ways.
The ribs should not be squeezed between the arms.
Only the fist pushed in the abdomen will be used.
It isnecessary to repeat the manoevre 5 up to 10 times if possible.

B Breath Ventilation

- Mouth to mouth, mouth to nose , mouth to tube ( the SAFAR tube, the Guedel
tube), mask ventilation ( the AMBU type balloon).
- If ventilation or intubation are not possible ( as in the case of a glottic edema)
the indispensable tracheostomy will be used and urgent trachael punction by
placing a trachea stome between thyroid and cricoid cartilage.
- The efficiency of the ventilation will be verified : the presence of breathing
movements; the cessation of cyanosis; symmetrical vesicular murmur.
 Rapid ventilation is attemped 2 times, followed by a cardiac massage and
alternative ventilation in a 30/2 ratio.

The rate of thoracic compressions is 100 per minute.

The frequency of mouth to mouth ventilation is 10-12 times per minute to an

adult and 10-12 per minute to a child.

AMBU TYPE BALLOON VENTILATION

The mask will be applied with the thumb and the index finger positioned above
the mouth and nose, the mandible will be kept backwards and with the fingers
left the head will be placed in extension position.

C Circulation

The circulation of the blood in the case of each cardiac arrest will be initiated
immediately while the precordial punch is being applied both ned with cardiac
massage.

External cardiac massage ( the patient in dorsal decubitus, placed on a hard

stand, is massaged in the 3rd inferior part of the sternum)

The frequency of the massage : 100 strokes per minute

the compression-decompression rate being > 50% compared to the
compression plate, about 4-5 cm.

Early defibrillation

- If in the 15 minutes the massage lacks efficiency, it can be continued for about
45-60 minutes in the presence of the patients family or friends or untill the
arrival of the qualified ambulance.

- in the case of ventricular fibrilation or T.P.S.V the massage will be continued

untill there will be means for electrical defibrillation.

DEFIBRILLATION AND EXTERNAL CARDIOVERSION

- indications : in cardiac arrest, ventricular fibrilation, atrial fibrilation, T.P.S.V

- device: electrical defibrilator provided with 2 metallic electrodes , its set up at
the lower part of the sternum and on the apical (V5);
- before applying electric discharge, the electrodes and the patients skin are
lubricated with an electroconductive paste, the power of defibrillation is set at
200-360 J for the thick wall, FV and 100-200 j for the thin wall, FA, TPSV.
 The discharge button is pressed and the patients body is violently jolted while
on the monitor the E.K.G is changing.

D- Drugs

The medical treatment

It is very important to achieve a peripheral venous acces way.

Thus, intravenously or through endotrachael tube in double or triple dose it can
be administered adrenaline 1 mg i.v. or 2-3 mg in 10 ml. s.f intratrachaelly,
atropine 0.5-2 mg in case of sinus bradycardia or asystole, lidocaine 1-3mg/kg
in order to prevent ventricular fibrilation relapses, or sodium bicarbonate 8,4 %
50-100ml.

PURSUED OBJECTIVES IN PROVIDING PREHOSPITAL MEDICAL CARE

In tackling the issue of a medical-surgical emergency the FD will have to take in

consideration the following objectives :
- the evaluation of emergency at first sight : is it or is it not an emergency?
- The nature of the emergency
- The cause
- The gravity
- The number of victims ( in case of casualities)
- The measures that have to be undertaken
- The succession of these measures
- The estimated time since the occurence of emergency untill the first taken
measures.
- Limiting the effect provoked by the primary agent
- The removal of the injured from the place of the accident
- Achieving a summary of the total injuries and a sorting of them after their
gravity
- Establishing the intervention priorities in the order of their vital urgency
- The application of first aid measures
- Positioning the victim in the right place, the treatment of the serious injuries,
immobilization,hemostasis, sedation, s.a.
- The appreciation of results after the undertaking of measures
- The FDs assuming of responsabilities to monitor the patient or to send him to
the hospital
- The evaluation of the risk factors during the transportation.

Acute myocardial infarction

Definition
Myocardial infarction (MI) is an ischemic necrosis of a cardiac muscle, secondary to
an obstruction on a coronary artery which has as a consequence a prolonged cellular
hypoxia.

The myocardial necrosis determines :

- a clinical syndrome
- E.K.G modifications produced by the reduction or even the cessation of
coronary flow
- the increase in the blood level of sensitive and specific biomarkers
( cardiac troponin I or T , creatine kinase MB fraction, total creatine kinase,
myglobin, SGOT).

The preffered marker for the myocardial trouble is cardiac troponin (I or T)

which has almost complete cardiac specificity and also, an increased
sensitiveness.
The best alternative is CK-MB, which is less specific then cardiac troponin, but it
exhibits a greater clinical specificity concerning the irreversible injury.

- morphopathological myocardial modifications.

The Initial Diagnosis

A working diagnosis of myocardial infarction has to be made in the first place.

This is usually based on the history of severe chest pain that lasts 20 minutes or
more and which doesnt respond to nitroglycerine.
The most suggestive details are linked with an earlier history of coronary illness, the
way the pain is radiated near the neck aria, in the mandible or along the left arm.
The pain may not be severe and other manifestations such as fatigue, dyspnea and
syncope are frequently encountered to older patients mostly.

During the physical examination the following aspects occur :

- the pacient is anxious and troubled

- pallor, cold and humid teguments;
- sweating
- bradycardial or tachicardic regular or erratic pulse ( arrhythmia)
- subcrepitant rales in left ventricular insufficiency (LVI)
- wheezing in LVI
- coughing combined with hemoptysis in pulmonary embolism or acute pulmonary
edema

Arterial hypotension appears in 3 circumstances :

- the extended anterolateral infarctions caused by pumping dysfunction;

 - inferior infarctions of a vagal reflexive nature;
- inferior infarctions with massive affectation of the right ventricle,
which leads to a deficit of blood filling of the left ventricle.

ELECTROCARDIOGRAM

An electrocardiogram has to be obtained as soon as possible.

Even in an early stage of infarction , the ECG rarely looks normal.
In the case of ST segment denivelation or a recently formed or presumed recently
formed left branch block, the therapy for reperfusion injury has to be administered
and measures for the initiation of the treatment have to be undertaken as soon as
possible.
Nevertheless, the ECG that is carried out in the first hours it might not show the
classical signs of ST segment denivelation or of recently emerged Q wave, even in
confirmed infarction.
The ECG repeated recordings have to be achieved and, when possible, the actual
ECG has to be compared with the previous lines.
Sometimes the recording of additional derivations can be useful ( in subsequent
infarctions V7, V8).
The monitoring with ECG has to be initiated as soon as possible to all the patients
in order to detect the malignant arrhythmias.

The initial diagnosis of acute myocardial infarction

- history of pain/ chest (thoracic) discomfort
- ST segment denivelation or left bunddle branch block ( presumed to be recently
formed) on the ECG.
Repeated ECG recordings are often necessary.
- increased myocardial necrosis markers ( CK- MB, troponin).
The results for the initiation of reperfusion treatment must not be waited for
( expected) !!
=
The two dimensional ecocardiography is useful in the diagnosing the acute
myocardial infarction .

The amelioration of pain, dyspnea and anxiety

Relieving the pain is of maximum importance, not only out of ethical reasons, but
also because pain is associated with the sympathetic activation which produces
vasoconstriction and increases the burden of the heart rate.
Intravenous opioids , morphine, when it is available, diamorphine, are the most
frequently used analgesics in this context, for exemple 4-8 mg of morphine with
additional doses of 2 mg at 5 minutes intervals untill the pain subsides. Repeated
doses can be necessary.

The side- effects include : nausea, and possibly vomiting, hypotension combined with
bradycardia, respiratory depression.
The antiemetics can be administered simultaneously with the opioids.
Hypotension and bradycardia usually react to the administration of atropine while
respiratory depression to nalaxonum.
If the opioids do not succeed to calm down the pain after repeated administrations,
intravenous beta-blockers or intravenous nitrates
are efficient in some cases.
Oxygen (2-4 l / minute on mask) has to be administered to those who suffer of
dyspnea mostly or to those who exhibit signs of cardiac insufficiency or shock.
Anxiety represents a natural reaction to pain and to those circumstances that
accompany a coronary accident. Alleviating the patients stress and their attendants
is extremely important. If the patient becomes excessively agitated he can be given
an anxiolytic but opioids are usually enough.

The alleviation of pain, dyspnea and anxiety

- Intravenous opioids ( for example 4-8 mg of morphine) with additional doses of

2 mg at intervals of 5 minutes
- Oxygen (2-4 l/ min ) if the patient shows signs of dyspnea or cardiac
insufficiency
- Beta-blockers or nitrates intravenously if the pain does not subside after the
administration of opioids
- Anxiolytics can be useful in this case.

Emergency conduct

The majority of deaths caused by AMI take place in the first hours after the
occurrence of the infarction.
In the prehospital phase 2 objectives influence the therapeutic attitude in the first
hours of the evolution of myocardial infarction.

- the prevention of malignant arrhythmia

- the early coronary reperfusion in the first 4-6 hours
- the prevention of malignant arrhythmia ( ventricular fibrilation, ventricular
tachycardia ) through lidocaine administration , magnesium sulphate or
metoprolol in perfusion.
- early coronary reperfusion in the first 4-6 hours through trombolytic agents
administration such as streptokinase, urokinase, tissue plasminogen activator
and anticoagulants such as heparin in bolus dose of 5000 UI followed by
prolonged perfusion in a dose of 1000 UI per hour.
Although it has been proven that lidocaine is able to reduce the incidence of
ventricular fibrilation during the acute stage of myocardial infarction, this type of
medication increases significantly the risk of asistolia.

Adjunctive antiplatelet therapy

Aspirin is better for the prevention of recurrent clinical events, then in the
maintenance of vessel patency. The first dose of 150-325 mg has to be chewed
( entersoluble capsules wont be administered), the ulterior daily dose being of 75-
160 mg.
 If their ingestion is not possible, the treatment will be administered intravenously
(250 mg)

Antiarrhythmics Drugs

Beta-blockers: They are used due to their potential of limiting the gravity of the
infarction, of reducing the rate of fatal arrhythmias and in order to alleviate the pain.

The atrial fibrilation complicates about 15-20% of myocardial infarctions and i tis
frequently associated with severe damages of the left ventricle and with cardiac
insufficiency.
Other supraventricular tachycardias are rare and , usually, self-limited.
They can react to the compression of carotid sinus.
If the rapid ventricular rate is one of the reasons of cardiac insufficiency , prompt
medical treatment will be neccessary.
Beta-blockers and digoxine are efficient in reducing the ventricular rate in many
cases, but amiodarone can be also efficient in reducing arrhythmia.
The external electric shock should be used if arrhythmia is poorly haemodinamically
tolerated.

Nitrates

the patient will receive a sublingual nitroglycerin tablet immediately after the onset
of chest pain susceptible of myocardial infarction,
if the pain did not give in five minutes, repeat a second administration, and if the
chest pain persists after another 5 minutes you can give the third tablet.
Patients treated with early intravenous nitrate had a significant reduction (a third)
mortality.

Angiotensin converting enzyme inhibitors (ACEI)

It is now well established that you may give ACE inhibitors to patients who have a
decreased ejection fraction or heart failure phenomena in an acute phase.
A systematic review of trials with ACE inhibitors administered early in the acute
myocardial infarction showed that this therapy is safe, well tolerated and associated
with a significant reduction in mortality at 30 days with a maximum of benefit
observed in the first week.
It is now a general consensus to initiate treatment with ACE inhibitors within the first
24 hours, in the absence of contraindications.

ACEI dose trials

GISS-3130 lysynopryl 5 mg initially to the 10mg/day
ISIS-4131 6.25 mg captopryl initially 12.5mg after 2h, 10-25mg to 50mg x 12h 2/day
SMILE206 zofenopryl 7.5mg initially, repeated after 12h and administration of
repeated double doses, if tolerated up to 30mg x2/day
AIRE205 ramipryl 2.5mg x 2/zi, is increasing by 5mg x 2/day
TRACE207 trandolapryl 0.5mg testing of up to 4mg/day
Glucose-insulin-potassium. The routine administration of glucose insulin potassium
metabolism may favorably influence the ischemic myocardium, thus leading to clinical
benefit.
 Criteria for evaluating the patient with myocardial infarction risk
Chances of survival of patients with AMI depends on:
of the atmosphere and how is the patient's reaction and his company reaction.
first measures applied to the patient's home and during transport to hospital
quick and easy access of population to mobile emergency care service (MECS)
specific technical equipment and training of the MECS teams

CARDIOGENIC PULMONARY EDEMA

DEFINITION:
Acute cardiogenic pulmonary edema (EPAC) is a form of paroxysmal severe
dyspnea due to excessive accumulation of interstitial fluid and its penetration into the
alveoli.
EPA necardiogen occurs in organo-phosphorus poisoning, in viral respiratory
infection, drowning, stroke, neurological diseases AVC

Most common precipitating factors encounter in practice are:

- Arrhythmias
- Acute coronary syndrome (IMA)
- Poorly controlled arterial hypertension
- Discontinuation of dietary salt restriction in ICC
- Strenuous exercise
Clinic:
revealing anamnesis for a suffering cardiac history
orthopnea and dyspnea with tachypnea
productive cough with foamy sputum, rosy-like, abundant
cyanosis
profuse sweating
extreme anxiety

EKG

- Paroxysmal arrhythmias
- Changes in ventricular hypertrophy
- Acute coronary syndromes

cardio-pulmonary X-ray:

possible cardiomegaly
dilated vessels in the hilum with blurred boundaries
fog lung fields especially in two thirds lower
 infiltrative changes with imprecise edges located perihilar (in butterfly wings)
any signs of pleural effusion in the pleural cavity or fissure

PULMONARY EDEMA TREATMENT

a. half-seated position:
- Is comfortable
- Allows easy breathing
- Facilitate expectoration
- Decreases venous return
- Usually in the EPAC is the only position that a conscious patient may adopt.

b. the sputum is aspirated and the oropharyngeal cavity of the patient is cleaned.
c. the preload is reduced by applying the tourniquet to the limb level (3 of 4) and will
be exchanged within 10-15 minutes

d. Oxygen: it is continuously administered 6-8 l / min.

e. Venous way stable, safe

f. Nitroglycerin:
- initially may be given 0.5 mg sublingual every 5 minutes till the hemodynamics is
improved or the arterial hypotension occurs (SBP <100 mm Hg)
Note that often the application only of these therapeutic sequences is sufficient.

g. Diuretics:
most of them employed are the loop ones.
furosemide: 40-120 mg i.v.
is relying primarily on its effect venodilatator which installs more quickly than the
diuretic one,
the diuretic effect installs in 20-30 min.

h. The administration of digitalis is useful for EPAC in atrial fibrillation with rapid
ventricular heart rate for the control of the ventricular allure at a dose of 0.5 - 2 mg
fractioned.

i. In EPAC accompanied by bronchospasm, Aminophylline 5 mg / kgcorp (240-480

mg) i.v. in 10 minutes is administered.
It is used with caution in cases of coronary artery disease and myocardial infarction
because it increases the risk of ventricular fibrilation.