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Cerebral resuscitation after cardiac arrest

Essentials 1 Neurological injury is common following out-of-hospital cardiac arrest and carries a high rate of morbidity and mortality. 2 Successful resuscitation leads to reperfusion of an ischaemic brain, and this may result in biochemical cascades, largely mediated by calcium influx into cells, promoting cell death. 3 In the early post-arrest period, the appropriate targets for oxygen, carbon dioxide, blood pressure and temperature are all uncertain,…

Arterial blood gases

Essentials 1 The value of arterial blood gas analysis is dependent on understanding and correctly interpreting the results in the clinical context. 2 When abnormalities are detected with arterial blood gas analysis, make sure that the sample was obtained, transported and analysed appropriately. 3 An arterial blood gas result assists in the assessment of a patient’s gas exchange, ventilatory control and acid–base balance. 4 Common sampling…

Sepsis and septic shock

Essentials 1 Early recognition and intervention in the emergency department reduces mortality in patients with sepsis and septic shock. 2 Appropriate broad-spectrum antibiotics should be administered within 1 hour of the recognition of sepsis. 3 Systemic blood pressure, serum lactate levels, and urine output should be monitored closely to determine the effectiveness of treatment. Introduction Sepsis is a leading cause of preventable death worldwide. Current estimates…

Shock overview

Essentials 1 Broad categories of shock include disorders of intravascular volume, vascular resistance, cardiac filling and the myocardial pump. Overlapping aetiologies are commonly encountered. 2 Hypotension is only one characteristic of shock, which should be considered a late and concerning finding. 3 Hypovolaemia and hence the need for volume resuscitation is a concern in every patient with shock. 4 Interventions in any form of shock are…

Haemodynamic monitoring

Essentials 1 Haemodynamic monitoring includes observation of the complex physiology of blood flow, with the aim of providing data that can be used to improve patient management and outcomes. 2 Numerous methods are available that should be considered in a stepwise fashion, from simple clinical assessment to highly technical, invasive procedures, such as use of the pulmonary artery catheter. 3 Effective use of haemodynamic monitoring devices…

Oxygen therapy

Essentials 1 Oxygen is the most frequently used ‘drug’ in emergency medicine. 2 Oxygen-delivery systems may be divided into variable-performance (delivering a variable concentration of oxygen) and fixed-performance (delivering a fixed concentration of oxygen, including systems that deliver 100% oxygen) types. 3 Fixed-performance systems are essential where precise titration of oxygen dose is required, as with chronic obstructive pulmonary disease (COPD) or where 100% oxygen is…

Airway and ventilation management

Essentials 1 Respiratory failure is a common presentation to the emergency department and ventilatory support may be required. 2 Non-invasive ventilation is appropriate for many patients with respiratory failure; endotracheal intubation and mechanical ventilation is used for cases where non-invasive ventilation is unsuccessful or contraindicated. 3 Rapid sequence intubation, using a sedative plus muscle relaxant drugs to facilitate endotracheal tube placement, is the default technique in…

Advanced life support

Essentials 1 Follow the Advanced Life Support (ALS) resuscitation guidelines developed by, or based on, those of the International Liaison Committee on Resuscitation (ILCOR). 2 Perform chest compressions without interruption for patients with no pulse, except when performing essential ALS interventions. 3 Deliver a shock to attempt defibrillation (150–200 joules [J] biphasic or 360 J monophasic) if the rhythm is either ventricular fibrillation (VF) or pulseless…

Basic life support

Essentials 1 A patient with sudden out-of-hospital cardiac arrest (OHCA) requires activation of the Chain of Survival, which includes early high-quality cardiopulmonary resuscitation (CPR) and early defibrillation. The emergency medical dispatcher plays a crucial and central role in this process. 2 Over telephone, the dispatcher should provide instructions for external chest compressions only CPR to any adult caller wishing to aid a victim of OHCA. This…

Tactical Emergency Medical Support and Urban Search and Rescue

Key Concepts Tactical emergency medical support (TEMS) facilitates the overall success and safety of law enforcement missions during all phases of a tactical operation through the delivery of preventive, urgent, and emergency medical care. A fundamental principle in tactical medicine is that the medical mission may be subordinate to the overall law enforcement mission. Tactical combat casualty care (TCCC) has adapted civilian advanced life support principles…

Weapons of Mass Destruction

Foundations Besides managing the injuries and illnesses from common disasters such as earthquakes and airplane crashes, emergency clinicians should also have competence in treating victims generated by terrorist attacks with chemical, nuclear, biologic, or high-energy explosive weapons. Conventional explosives remain the most common weapon used by terrorists; however, the risk from nuclear, biologic, and chemical agents may increase over time. The nomenclature for these weapons is…

Disaster Preparedness

Key Concepts Comprehensive emergency management consists of four phases: mitigation, preparedness, response, and recovery. Mass casualty planning should account for the breakdown of traditional transportation and communications systems during a disaster. Field personnel should be specifically trained in mass casualty triage and stabilization because austere field conditions change management strategies. All plans must protect caregivers and rescue personnel. Critical incident stress management is highly desirable after…

Air Medical Transport

Key Concepts Air medical transport (AMT) is a critical component of a comprehensive health care system and a vital link for rural communities and critical access hospitals to distant emergency care. Boyle’s law and Dalton’s law have the greatest impact and explain the development of hypoxia and most common altitude-related symptoms. Other stresses of flight that can affect the patient or crew include temperature fluctuations, dehydration,…

Emergency Medical Services: Overview and Ground Transport

Key Concepts Published in 1966, Accidental Death and Disability: The Neglected Disease of Modern Society by the National Academy of Sciences–National Research Council was instrumental in emergency medical service (EMS) maturation in the United States. There are multiple models for EMS systems, including public and private services, those operating at basic and advanced levels of care, and those including single or multiple tiers of response capability.…

Forensic Emergency Medicine

Key Concepts Knowledge of wound mechanics, production, and appearance can provide practicing emergency clinicians with important clues regarding the forensic interpretations of injuries. Wounds and injuries should be diagrammed and photographed. The medical record should accurately document objective findings associated with a patient’s wounds. Emergency clinicians should not speculate about their mechanism or cause. For the chain of custody to be preserved, any evidence collected during…

Wellness, Stress, and the Impaired Physician

Key Concepts Physician Wellness: A quality of life that includes the presence of positive physical, mental, social, and spiritual well-being experienced in connection with activities and environments that allow physicians to develop their full potentials across personal and work-life domains. Physician Burnout: A work-related syndrome characterized by emotional exhaustion, depersonalization, and a sense of reduced personal accomplishment. It is frequently associated with chronic stress and emotionally…

Patient Experience in the Emergency Department

Key Concepts Factors that can improve the patient experience in the emergency department include: Communication that expresses empathy Working as a high-functioning team Setting realistic expectations regarding wait time Clear discharge instructions Improvement in the patient experience has been shown to impact composite outcomes such as health-related quality of life to patients, reduced malpractice risk, and improved staff satisfaction. Foundations Patient experience is a growing area…

Quality Improvement and Patient Safety

Key Concepts The work of health care occurs within a complex socio-technical system so that a change in even one component has an impact on other parts of the system and ultimately on safety. Patient safety and mitigation of risk emerges from multifactorial interactions within the clinical work system. Incidents of patient or staff harm are most often the result of system failures, not individual human…

Emergency Medical Treatment and Labor Act and Medicolegal Issues

Key Concepts The Emergency Medical Treatment and Labor Act (EMTALA) governs virtually every aspect of hospital-based emergency services. Centers for Medicare and Medicaid Services (CMS) deems anyone on hospital property to have “come to the emergency department.” Hospital property consists of the entire main hospital campus, including parking lots, sidewalks, and driveways, and any ambulance owned and operated by the hospital, even if the ambulance is…

Bioethics

Key Concepts Bioethics is a method of using values and moral principles to come to defendable decisions for ethical dilemmas . In emergency medicine, many ethical dilemmas often go unrecognized. Ethical dilemmas arise from conflicts between multiple good options or multiple bad options, not between good and bad choices. Values come from a variety of sources: community, culture, religion, and family. The values driving medical decisions…