EMERGENCY MEDICINE

DR F DERY
SUNYANI MUNICIPAL HOS[PITAL
 Outline

• Classification of Emergencies
• General Principles of Emergency Care
• Tools used in emergency care and improvisation
• Transportation/referral of victims
• Disasters and their management
• Diagnosis of specific emergencies and management
- Bleeding
- Shock
- Poisons
- Bites and stings
- Unconsciousness/coma
- Asphyxia
- Epilepsy, convulsion
- Drowning
- Bandages and bandaging
 Classification of Emergencies

An emergency condition is one that can permanently impair or

endanger the life of an individual in which immediate action is
necessary.
Emergencies can be classified into:
1. Life-threatening conditions- these include:
• Severe chest pain or difficulty breathing
• Compound fracture
• Seizures, convulsions or loss of consciousness
• Heavy, uncontrollable bleeding
• Gunshot/deep knife wound
• Moderate to severe burns
• Poisoning
• Pregnancy-related problems
• Severe abdominal pain
• Stroke
• Suicidal feelings
• Fever in newborn(<3 months)
2. Urgent medical condition- patients with illness or
injury that does not appear to be life-threatening,
but also cannot wait until the next day(require care
within 24 hours). Examples include:
• Sprains and strains
• Mild to moderate asthma
• Moderate back pains
• Diagnostic services- x-ray, lab
• Eye redness and irritation
• Vomiting, diarrhoea or dehydration
• Minor fractures- fingers and toes
• Falls
• UTI
• Sore throat
 General Principles of Emergency Care

Steps in Emergency Care

• Triage
• Primary survey
• Secondary survey
• Stabilization
• Transfer
• Definitive care
NB. Start resuscitation at the same time as making the primary
survey.
Do not start the secondary survey until you have completed
the primary survey.
 Triage
Simply means sorting and treating patients according to
priority if there is more than one injured person. Is a
method of ranking sick or injured people according to the
severity of their sickness or injury in order to ensure that
medical and nursing staff and facilities are used most
efficiently.
The tools used in triage are in 2 parts:
- Triage Early Warning Scores(TEWS)
- Discriminator List
Before moving to the discriminator list you have to calculate the
total TEWS.
The basic vital signs observed in TEWS include:
- BP and Heart Rate
- Respiratory Rate
- Temperature
- AVPU
- Mobility
- Trauma- presence of any injury
Discriminator- generates the triage colour (red, orange, yellow,
green, blue)
• Red- patients whose injury is critical but require only minimal
time or equipment to manage, and have good prognosis of
survival eg compromised airway, massive external
haemorrhage. They are referred to the resuscitation room for
emergency management
• Orange- patients with debilitating injuries but who do not
require immediate management to salvage life or limb.eg long
bone fractures. They are referred to the waiting area for urgent
management
• Yellow- patients whose injury is so severe that they have only
minimal chance of survival eg 90% full thickness burns. Referred
to waiting area for management
• Green- patients with minor problems that can wait
for treatment or may even be of assistance to
comfort other patients. They are patients for
potential streaming.
• Blue- any patient who is unresponsive, pulseless and
breathless. They are referred to the doctor for
certification
 Adult Triage Score
3 2 1 0 1 2 3

Mobility walking With Not

help mobile
RR <9 9-14 15-20 21-29 >29

HR <41 41-50 51-100 101-110 111-129 >129

SBP <71 71-80 81-100 101-199 >199

Temp <35 35-38.5 >38.4

cold hot
AVPU confused alert React to React to Not
voice pain responsive
Trauma no yes
 Adult Discriminator

Adult Discriminator
COLOUR Red Orange Yellow Green Blue

TEWS 7 or 5-6 3-4 0-2 dead

more
NB: We have triage scores for children 3-12 years and <
3 years
Example: a man with the following triage scores: RR=1
HR=2 mobility=1 SBP=0 Temp=0 AVPU=0 Trauma=1
Total Triage Score=5. This man would be labeled
ORANGE and needs urgent management
 Flow Chart For Triage
Step 1- take brief history directed at main complaint
Step 2- measure vital signs and document
Step 3- calculate the TEWS and document the total
values
Step 4- match score to discriminator list
Step 5- document the triage code and act immediately
 Primary Survey
This is the first survey and if performed correctly you
would be able to identify life threatening injuries.
Previously the first in primary survey was to carry out
the ABCDE of life.
A– Airway
B– Breathing
C– Circulation
D– Disability
E– Expose

Currently (a school of thought in trauma- cardiac

arrest) the sequence is CABDE. The C is chest
compression and the rest of the letters is the same
1 . Airway- No oxygen can reach the tissues if the airway
is obstructed. The commonest cause of obstruction is
unconsciousness in the supine position which causes
the tongue to fall back closing the pharynx. Other
causes of airway obstruction include neck trauma
and foreign bodies. Assess the airway for:
• Patency-Can the patient talk- must therefore have a
clear airway
• Airway obstruction
i. Snoring
ii. Stridor or abnormal breath sounds
iii. Agitation
Iv. Using accessory muscles of respiration
v. Cyanosis
Management of the Airway Obstruction
• Chin lift or jaw thrust- manually elevating the angles
of the mandibles. Be careful not to hyperextend the
neck. There might be cervical injury.
• Remove secretions, blood clots, foreign bodies.
• Insert an oral airway into the mouth behind the
tongue
• Inset a nasopharyngeal airway via the nostril
• Give oxygen
• Advanced techniques- intubation, tracheotomy.
2. Breathing- even with an open airway no oxygen
reaches the lung unless the patient is breathing or
someone provides artificial ventilation. Breathing
may stop in these conditions: severe head injury,
hypoxia, circulatory arrest.
Assess breathing- look for breathing (respiratory rate),
look for cyanosis, auscultate the lungs.
Management- maintain on oxygen and ventilate until
patient is completely stable.
3. Circulation- oxygen in the lungs cannot reach the
tissues unless the heart is working. Common causes
of inadequate circulation include blood loss (shock)
or increase pressure on the heart (pneumothorax,
haemoperitonium )
Assessment of circulatory failure- increase pulse rate,
low BP, obvious/concealed bleeding, long capillary
refill time.
Management- the goal is to stop bleeding, obtain
vascular access, give IV fluids (normal saline), take
blood for grouping & crossmatching.
4. Disability- do not make full neurological examination
at this stage. Grade the patients level of
consciousness using a simple classification as AVPU
A- Alert
V-Verbal response
P- Response to Pain
U- Unresponsive
• 5. Expose- remove the patient clothing and examine
the whole patient so that you do not miss other
injuries.
 Resuscitation

• Literally means revive somebody from

unconsciousness or apparent death. Three elements
are involved in getting oxygen to the brain and other
vital organs. The airway must be opened so that
oxygen can enter the body; breathing must take
place so that oxygen can enter the blood via the
lungs and blood must travel around the body
(circulation) taking oxygen to all the tissues and
organs to revive the patient.
Anybody breathing is alive
Anyone not breathing needs resuscitation
1. First thing to do is chest compression
2. The second thing to do is ventilation
3. Third is defibrillation if available
4. Fourth thing to do is to give Advanced Live Support
(ALS)
NB. You need 4-6 people to resuscitate effectively
 Basic Life Support

• Approach the victim safely- ensure that the area

around the victim is safe.
• Check response- ask: are you OK? If no response
check for breathing (no breathing or only
gasping) and then check the carotid pulse by
locating the crico-thyroid cartilage and sliding to
the side. If pulse not present then;
• Shout for help or send second rescuer if available
to do this(note one person cannot resuscitate
effectively)
In Adults
• Check pulse and if definite pulse within 10seconds
- Give 1 breath(rescue breaths) every 5-6 seconds
- Recheck pulse every 2 minutes
• If no definite pulse within 10 seconds
- Begin cycles of 30 compressions and 2 breaths by
mask until 2nd rescuer arrives and he/she takes over
the chest compressions and you the 2 breaths.
• Continue for 5 cycles whilst changing roles not to be
exhausted. Continue until the AED (Automatic
External Defibrillator) is brought by the 3rd rescuer
and does the connection whilst you continue with
the chest compression. When the AED is ready you
all stay away from the victim and 3rd rescuer give 1
shock and you resume CPR immediately. If AED is not
available continue with the CPR until ALS(Advanced
Life Support) providers take over or victim moved to
Hospital.
Compress chest at the middle of the nipple line if a
male. If a female midway between sternal notch and
xiphoid process.
Place your active palm at that point and use the
second hand to clench the first with the arms straight
and your body over the victim to give your weight
and not your muscles and compress whilst counting
the number of compressions aloud so that the other
team members would know when to give the
breaths. Push hard, push fast. Allow complete chest
recoil after each compression & effective breaths
that make chest rise.
In Paediatric Cases
• Check pulse and if definite pulse in 10 seconds
(palpate with 2 fingers at medial aspect of arm to
check the brachial pulse)
- Give 1 recue breath every 3 seconds
- Add compressions if pulse remains <60/min
- Recheck pulse every 2 mins
• If no pulse
- And only one rescuer shout for help and begin cycles
of 30 compressions and 2 breaths.
- If 2nd rescuer arrives begin cycles of 15 compressions
and 2 breaths for 10 cycles ( Note that adults is 5
cycles of 30 compressions and 2 breaths)
- Use AED as soon as it is available by giving 1 shock
- Then continue the CPR immediately for 2 mins
- Continue until ALS takes over or victim transported
to hospital
For paediatric chest compression you use 2 finger tips
(index and middle fingers) just below the nipple line
if you are the only rescuer whilst standing at the side
of the victim until the 2nd rescuer arrives to takeover
the breaths. You then move to the bottom of the
victim and put both palms at the sides of the lower
chest with the thumbs just below the nipple line and
do the compressions.
Push hard, push fast.
Give ALS
1. Secure airway- oral airway, endotracheal tube, etc.
Give 100% oxygen 3-5 litres
2. Set intravenous/intra-osseous line within 6 minutes
3. Give adrenaline 1mg every 3-5 minutes to increase
the pressure
4. Give amiodarone 300mg single dose to help in the
defibrillation
 Choking

In Adults
• Go behind the victim and locate the umbilicus and
make a fist with one hand and support with the other
hand and place it just above the umbilicus and make
a sudden upwards thrust. May need to repeat. If
victim is fat at the trunk move your fist to the chest.
If victim not improving support him/her gently from
behind to lie on the back and check mouth to
remove dislodged material and start CPR until ALS
takes over.
Paediatric
• whilst sitting place baby on your outstretched palm
and forearm supine on your thigh with head lower
than body and using your index and middle fingers
give 5 thrusts below the nipple line. Then turn prone
and give 5 back thrusts with the ball of the palm.
May repeat the process. If not succeeded continue
with CPR until ALS is available.
 Secondary Survey

The purpose of secondary survey is to examine all

systems of the body. An x-ray if available is part of
the secondary survey. Undertake head-to-toe
examination noting particularly the following:
1. Head
• Scalp and ocular lesions
• External ear and tympanic membrane
• Periorbital soft tissue
2. Neck
• Penetrating wounds
• Subcutaneous emphysema
• Trachea deviation
3. Neurological
• Glasgow coma scale
• Spinal cord motor activity
• Sensation and reflex
4. Chest
• Clavicles and ribs
• Breath and heart sounds
5. Abdomen
• Penetrating abdominal wounds
• Blunt trauma
• Rectal examination
6. Pelvis and limbs
• Fractures, peripheral pulses, cuts & bruises
7. X-rays where indicated
 Stabilization and Transfer

After you have treated the life threatening conditions

and made a secondary survey to detect any other
injuries and made the patient stable you can now
decide to:
• Transfer to the ward
• Transfer to theatre
• Transfer to x-ray
• Transfer to another hospital
 Definitive Treatment

Once the patient has been resuscitated, stabilized and

transferred the correction of the injury can proceed.

Strategy for Multisystem Trauma Patient Care

• Evaluate the 3 S- Safety, Scene, Situation
• Rapidly assess the patient’s systemic condition-
perform the rapid CAB and spine survey focusing on
ventilation, shock and haemorrhage control
• Provide interventions for these problems as they are
found
• Reassess vital functions to evaluate the effectiveness
of the interventions
• Assess the head, chest and abdomen to locate
potentially life threatening conditions and rapidly
provide interventions for any that are found
• Immobilize patient and expedite transport to
appropriate facility
• Perform rapid secondary survey and provide
treatment enroute to the hospital
 Tools Used in Emergency Care and Improvisation

• Jump-bag- carries most of surgical sundries(bandages, drips,

syringes, etc)
• Bag valve mask- used to manually give rescue breaths to a
patient who is not breathing or breathing inadequately
• Suction unit- to suction secretions and fluids from the
patient’s airway
• Medications bag- used by paramedics and the size and type
of medicines depend on the qualification of the paramedics
• Trauma/spinal board- patient handling stretchers used to
provide rigid support in patients who have suspected spinal
injuries. They can also be used to carry any patient over a
short distance
• ECG monitor with defibrillator- the most basic
models are automated and the paramedic attaches
the monitor to the patient and follow the voice
prompts from the monitor. The ECG monitor is to
display the patient’s ECG on a built in screen so that
it can be monitored by the paramedic and the
defibrillator is used to shock cardiac arrhythmias.
• Incubators- these are used to keep neonates warm
while being transported in the ambulance
• Infusion pumps and syringe drivers- they control the
rate at which an infusion is infused to a patient
• Glucometer- is used to check patient’s glucose level
• Cervical collar(neck brace)- placed around the neck
of patients suspected to have head or neck injury to
minimize movement which could worsen the injury
• Kendrick Extrication Device(KED)- used to remove
victims of traffic collisions from motor vehicles. It
secures the head, neck and torso in an anatomically
neutral position, reducing the possibility of additional
injuries to these regions during extrication out of the
vehicle.
Improvisation applies when you have used all the Tools
 Transportation/Referral of Victims

Transportation should begin as soon as the patient is

stabilized for the ride to the hospital. Ensure:
• Secure airway
• Continued evaluation and further resuscitation en
route to the hospital
• IV line- do not delay because of IV access
• Patients with altered conscious state and potential to
become violent should have wrist and ankle
restraints applied and secured to the cot
• NG tube if indicated
• Cardiac monitor and pulse oximeter initiated
• Warming measure(blankets) if indicated
• Other procedures are initiated if indicated
• Patients with potential for spinal injury will be secured
as follows:
- Backboard
- Cervical collar or blanket rolls
- Secure with straps at chest, hip and knee levels
• Family members are counseled of the situation and
given directions to the receiving hospital
• The facility to which the patient is transported should
be determined by the severity of the patient
condition
- The patient should be taken to the hospital which will
provide definitive care of the patient’s problem as
quickly as possible
- The closest hospital with an on-call team ready to
treat the patient immediately is the appropriate
hospital
 Disasters

Is a serious disruption of the functioning of a

community or society involving widespread human,
material, economic or environmental losses and
impacts, which exceeds the ability of the affected
community or society to cope using its own resources
Classification
• Natural disasters- floods, hurricanes, earthquakes,
volcanic eruptions, landslides, tsunamis
• Environmental emergencies- forest fires, industrial
accidents(involves production, use, and
transportation of hazardous material)
• Complex emergencies- break-down of authority,
looting and attacks on strategic installations, conflict
situations and wars
• Pandemic emergencies- sudden onset of contagious
disease that affect health, disrupts services and
business, brings economic and social costs
 Factors Affecting the Effects of Disasters
• Poverty- the greater the poverty the higher the impact
• Increased population density- the higher the population
at the centre of a disaster event the greater the impact
on that disaster
• Rapid urbanization- poor planning and provision of safe
infrastructure can be an aggravating factor in the
severity of disasters eg rapid building construction in
urban areas may be short of good building practices
• Environmental degradation- removal of trees and forest
cover from a watershed area cause larger volumes of
surface runoff after a storm.
• Lack of awareness or preparation for common
disasters
• War and civil strive
• Sociopolitical issues

Public Health Impact of Disasters

These can be divided into 4:
• Direct impact on health of the population- the
impact is that of injuries and deaths
• Direct impact on health care system- health facilities
and staff are subject to the same destructive forces
as other buildings and people in the area of disaster
• Indirect effect on health of the population- these
effects result partly from the loss of routine health
care as a result of damage to the health care system
and overloading the system with trauma- related
care.
• Indirect effect on the health care system- these
indirect impacts result from increased usage of the
system and impacts on the infrastructure upon which
the health system relies.
 Management of Disasters
There are 4 phases of emergency management:
• Disaster prevention(mitigation)- these are activities
designed to provide permanent protection from
disasters. Not all disasters can be prevented eg
natural disasters, but the risk of loss of life and injury
can be mitigated with good evacuation plans. This
involves changes in local building codes to fortify
buildings; revised zoning and land use management;
strengthening of public infrastructure an other
efforts to make the community more resilient to a
catastrophic event.
• Disaster preparedness- these activities are designed
to minimize loss of life and damage. Removing
people and property from a threatened location and
facilitating timely and effective rescue, relief and
rehabilitation. Preparedness is the main way of
reducing the impact of disasters
• Disaster relief(response)- this is a response to reduce
the impact of a disaster and its long term effects.
These activities include rescue, relocation, providing
food and water, preventing disease and disability,
providing temporary shelter and emergency health
care, repairing vital services such as telecom,
electricity, water, transport
• Disaster recovery- is restoration of all aspects of the
disaster’s impact on the community and the return
of local economy to normalcy. Recovery activities
include rebuilding infrastructure, health care and
rehabilitation, developing policies and practices to
avoid similar situations in the future
 Mass Casualty Management
Arrangements to deal with a mass casualty include the
following procedures:
• Discharge less acutely ill patients
• Cancel elective procedures
• Add additional beds to wards and rooms
• Set up cots in open spaces
• Establish procedures to call back staff for extra shifts
• Increase stocks of equipment, supplies and
pharmaceuticals
 Diagnosis of Specific Emergencies and Management
1. Bleeding

Types of Bleeding
1 Vessel Involved
• Arterial bleeding is bright red, spurts as a jet which
rises and falls in time with the pulse.
• Venous bleeding is dark red and escapes as a
steady flow
• Capillary bleeding is bright red and often rapid ooze
2. Commencement of bleeding
• Primary haemorrhage: occurs at time of injury or
operation.
• Reactionary haemorrhage: follow primary haemorrhage
within 24hrs and mainly due to slipping of ligature or
dislodgement of a clot.
• Secondary haemorrhage: occurs after 7-14 days and it is
due to infection and sloughing of part of the wall of an
artery.
3. Internal (Concealed) bleeding: bleeding may occur but not
seen externally as in: ruptured spleen, ruptured ectopic
gestation.
4. External (revealed) bleeding: concealed haemorrhage may
become revealed as haematemesis or malaena from
Peptic Ulcer Disease (PUD)
 Examples of Bleeding in Practice
1. Wounds
2. Bleeding PUD
3. Bleeding haemorrhoids
3. Trauma
• Extremities injury (fractures)
• Head injuries
• Chest injuries
• Abdominal trauma: ruptured spleen, ruptured bladder,
laceration of liver and other viscera.
 Bleeding PUD

Clinical Features
• Haematemesis
• Malaena
• Bright red blood per rectum in severe bleeding
• Pallor, cold clammy skin and signs of shock
• There may be history of PUD
• There may be no previous ulcer history(upper abdominal
pain, dyspepsia)
• Pain, tenderness and rigidity(signs of peritonitis) may be
absent initially
Differentials
• Haemoptysis
• Vomiting of swallowed epistaxis blood
• Bleeding oesophageal varices
• Erosive gastritis
• Carcinoma of stomach
• Oesophagitis
• Blood dyscrasias
• Overdosage of NSAIDs/ anticoagulants
 Treatment

• Establish a large bore iv line and resuscitate with N/S

or Ringers lactate
• Aspirate blood from the stomach with a nasogastric
tube in an unconscious patient to prevent aspiration
• Monitor BP, pulse
• Transfuse if patient is hypotensive or lost more than
1litre of blood
• Give IV omeprazole 40mg 12hourly
• Refer for surgery if bleeding persists
 Ruptured Spleen

Causes
• Traffic or industrial accidents
• Blows on the abdomen or left lower thorax
• Falls onto a projected object
Cases of ruptured spleen may be divided into
two:-acute and delayed
Acute
There is an initial shock ; recover from shock and
then show signs of ruptured spleen:
1 General signs of internal haemorrhage:-increasing
pallor, a rising pulse rate, sighing respiration and
restlessness.
2 Local signs
• Abdominal rigidity most pronounced in the left upper
quadrant
• Local tenderness
• Shifting dullness in the flanks
• Abdominal distension commences 3hrs after the
accident and is due to intestinal paresis
• Pain referred to the left shoulder. This is due to blood
in contact with the under surface of the diaphragm
• Rectal examination frequently reveals tenderness
and often soft swelling due to blood clot in the
rectovesical pouch
 Delayed

After the initial shock have passed off the symptoms of

serious intra-abdominal injury are postponed for a
variable period of up to 15 days or more. These cases
only collapse later from internal haemorrhage. The
reasons for the delay are:
• The greater omentum as a policeman, shuts off that
portion of the peritoneal cavity in the immediate
vicinity of the bleeding
• A subcapsular haematoma forms and later burst
• Blood clot sealing the rent becomes digested
 Investigations

• FBC, grouping and cross matching

• USG- a dent or discontinuity or irregularity of the border of
the spleen
• Plain abdominal x-ray
• Laparoscopy- direct vision of blood and the tear

Treatment
Pre-operative resuscitation by blood transfusion, IV line(N/S),
oxygen, elevation of foot end of bed, may be necessary, but
this should be followed by early laparotomy and splenectomy.
 Ruptured bladder

Rupture of the bladder occurs from direct violence or

as a result of fracture of the pelvis. The rupture may
be intraperitoneal or extraperitoneal; the later is
more common.
• Intraperitoneal rupture occurs when the bladder is
full and may occur after trauma. Urine escapes into
the abdominal cavity resulting in peritonitis with pain
in the lower abdomen, tenderness and guarding
associated with failure to pass urine.
• Extraperitoneal rupture is an occasional complication
of fracture of the pelvis. A significant feature is
swollen soft tissues of the groin extending to the
scrotum as a result of extravasated urine. The patient
may pass only small drops of blood when attempting
to urinate
• Treatment of ruptured bladder
Urgently refer to a surgical specialist for repair of the
rent followed by urethral catheter drainage.
 2. Shock

It is a critical condition that is brought on by a sudden drop in blood flow

through the body. The circulatory system fails to maintain adequate blood
flow, curtailing the delivery of oxygen and nutrients to vital organs.
Signs and Symptoms
• Low BP(hypotension)
• Hyperventilation
• Weak rapid pulse
• Cold, clammy , pale skin
• Cyanotic skin
• Oliguria
• Confusion
• Dizziness or fainting
• Weakness or fatique
 Stages of Shock
• Initial- the cells become leaky and switch to
anaerobic metabolism
• Non-progressive(compensated stage)- attempt to
correct the metabolic upset of shock
• Progressive(decompensated)- eventually the
compensation will begin to fail
• Refractory- organs fail and the shock can no longer
be reversed
Types of Shock
• Septic shock- due to infection
• Anaphylactic shock- by allergic reaction
• Cardiogenic shock- due to heart problems
• Hypovolaemic shock- by too little blood volume
• Neurogenic shock- damage to the nervous system
Anaphylactic shock
It is a life-threatening but rapidly reversible condition if treated
promptly
Causes
• Bee/insect stings, drugs(penicillin, sulphonamides, contrast media)
• Anti-sera(anti-snake, ATS), vaccines
• Foods- eggs, fish, seafood, groundnuts, fruits,
peanuts, strawberry, semen
• Latex
Clinical Features
• Itching, urticaria, oedema(facial, periorbital), wheeze
• Cyanosis, tachycardia, hypotension, cold clammy
extremities
Treatment
• Oxygen + adrenaline IM 0.3-0.5ml of 1:1000 solution
and repeat every 10mins + hydrocortisone 100-200mg
6-8 hrly to control late allergic reaction
• Then prednisolone 40mg daily x 14 + promethazine
hydrochloride IM 25mg repeat after 2hrs or
chlorpheniramine IM 5-10mg 6 hourly
• Nebulized salbutamol if severe airway obstruction or
aminophylline IV 250mg over 20 mins
• Normal saline 1-4litres if severe hypotension
 Cardiogenic Shock
Shock caused primarily by the failure of the heart to
maintain the circulation
• Causes- myocardial infarction, arrhythmias, cardiac
tamponade, tension pneumothorax, pulmonary
embolus, endocarditis, myocarditis aortic dissection
• Clinical features – depend on the cause
• Treatment- identify the cause and treat accordingly
 Hypovolaemic Shock
• Causes
- bleeding- trauma, ruptured ectopic
- Fluid loss- vomiting, diarrhoea, burns
- Heat exhaustion
• Treatment
- Fluid replacement- N/saline
- Blood if bleeding
- Treat underlying cause
- Tepid sponging and fanning if heat exhaustion. Avoid ice
 Septic Shock
Severe sepsis with hypotension despite adequate fluid
resuscitation or vasopressors/inotropes to maintain blood
pressure
• Causes- severe sepsis with gram –ve or +ve bacteria
• Treatment
- If no clue to source- IV cefuroxime1.5gm 6-8 hourly
- Give colloid or crystalloid IV
- Low dose steroids may help
- Blood culture and sensitivity for specific treatment
 Neurogenic Shock
is difficult because spinal cord damage is often
irreversible. Immobilization , anti-inflammatory drugs
and surgery
Treatment of shock in General
• Lay person down and raise feet unless you suspect head,
neck, back or limb injuries
• Begin CPR if person is not breathing or breathing seems
dangerously weak
• Get IV access
• Identify and treat underlying cause(except cardiogenic cause)
• Infuse crystalloid to raise BP(dictated by BP and urine output)
• Carryout investigations
 3. Poisons

• Poison-any substance (solid, liquid or gas) that is

harmful to the body when ingested , inhaled or
absorbed through the skin. This does not include
adverse reactions to medications taken correctly.
How Poisoning Occur
• Overdosing of medicines
• Bitten or stung by venomous animals
• Swallowing or sniffing paints
• Coming into contact with poisonous chemicals
• Touching/eating poisonous plants
• Inhaling poisonous gases or fumes from cleaning
products
• Pesticides
• Petrochemical products
• Illegal drugs
• Household cleaning products
 Type and Circumstances of Poisoning

• Acute- a single contact that lasts for seconds,

minutes or hours.
• Chronic- is contact that lasts for many days, months
or years
• Intentional/Deliberate- a person taken or given a
substance with the intention of causing harm
(suicidal, criminal, dependence, abortion)
• Unintentional/Accidental- a person taken or given a
substance that did not mean to cause harm
(overdose, at work, at home, environment)
Routes of exposure
ingestion
inhalation
skin contamination
eye contamination
injection (drug overdose)
snake, animal or insect bite
Effects of Poisoning
May be none, mild or severe depending on: i)amount of
poison ingested(dose) ii)nature of substance iii)age of person
iv)nutritional status of person v)state of the stomach(full or
empty)
 Mechanisms of Action
- Interfere with the transport or tissue utilization of oxygen-
carbon monoxide
- Depress/stimulate CNS- narcotics
- Affect autonomic nervous system-organophosphate
- Affect lungs by aspiration- hydrocarbons
- Affect the heart/myocardial function- antidepressants
- Produce local damage/GIT- caustics Affect the
liver- acetaminophen Affect cells- cyanide
- Affect blood- heavy metals
 Diagnosis of Toxins
In general, the steps leading to the diagnosis of
poisoning are as follows:
• Recognition- it may easily be observed that someone
has taken poison if:
- Chemical products are evident at the scene
- Drugs on or around the scene
- A syringe is in or next to the victim
• Questioning the patient or relatives or co-workers
concerning the presence of poisons in the environment
• Take a careful history and perform a complete physical
examination and make a differential diagnosis
• Take samples for laboratory evaluation of:
- Damage to specific organs
- Confirm or rule out exposure to specific poisons
Specimens ordinarily examined are tissue samples,
blood or urine, food, drink, gastric contents and
suspected poison itself.
Gastric contents usually have the highest concentration
of poisons if ingested.
• X-ray evaluation
Medications visible on X-ray (CHIPES)
- Chloral hydrate
- Heavy metals
- Iron
- Phenothiazines
- Enteric coated pills
- Sustained release medications
 Summary of Symptoms and Signs

1. Odour
• Acetone- isopropyl alcohol, methanol
• Alcohol- ethanol
2. Eyes
• Miosis(constriction of the pupil of the eye)- organaophosphates,
muscarinic mushroom, barbiturates, narcotics
• Mydriasis (dilation of the pupil of the eye)- atropine, alcohol,
cocaine, cyanide, antihistamines, carbon monoxide,
amphetamines
• Nystagmus(involuntary rapid movement of the eyeball)-
ethanol, barbiturates, phenytoin, Co
• Lacrimation- organophosphate, irritant gas or vapour
• Poor vision- methanol, Co
3. Skin
• Erythema- mercury, cyanide, boric acid
• Bullae- barbiturates, Co
• Alopecia- mercury, lead arsenic
• Dry/hot skin- anticholinergic agents
• Diaphoresis(sweating)- organophosphate, muscarinic
mushroom, cocaine, aspirin
4. Mouth
• Salivation- organophosphates, salicylates, corrosives
• Dry mouth- antihistamine, amphetamines
• Burns- corrosives
• Dysphagia- corrosives
• Gum lines- lead, mercury, arsenic
5. Intestinal
• Cramps- arsenic, organophosphates
• Diarrhoea- antimicrobial, arsenic, iron, boric acid
• Constipation- lead, narcotics
• Haematemesis- corrosives, iron, salicylates,
aminophylline
6. Cardiac
• Tachycardia- atropine, aspirin, cocaine, amphetamines
• Bradycardia- beta blockers, calcium channel blockers,
mushroom, organophosphates, digitalis
• Hypertension- cocaine, amphetamines
• Hypotension- beta blockers, calcium channel blockers,
iron, barbiturates, phenothiazines
7. Respiratory
• Decrease- alcohol, narcotics, barbiturates
• Increase- aspirin, amphetamines, cyanides, Co
• Pulmonary edema- hydrocarbons, aspirin, heroin,
organophosphates
8. CNS
• Coma- sedatives, barbiturates, organophosphates,
Co, salicylates, cyanide
• Ataxia(irregular jerky movements & unsteadiness in
standing and walking)- alcohol, barbitrates, antidepressants
• Hyperpyrexia- quinine, salicylates, cocaine, amphetamines
• Muscle fasiculations- organophosphate
• Muscle rigidity- phenothiazines, haloperidol
• Paraesthesia- cocaine, camphor
• Peripheral neuropathy- lead, arsenic, mercury,
organophosphate
• Altered behaviour- alcohol, cocaine, camphor,
amphetamines
 General Principles of Treatment

1. Resuscitation and Stabilization

2. Determine type/severity of poison
3. Decontamination(Prevention/Removal/Reduction of
Absorption)
- GIT decontamination
- Surface decontamination
4. Antidotes
5. Supportive care
6. Enhancement of Excretion
 First Aid
NB: Lay persons should not attempt treatment if the
patient is convulsing or unconscious.
a. Ingested poison
- Have the patient drink one of the following to dilute
the poison and slow absorption: milk, beaten white
of an egg, suspension of flour, water
- Give activated charcoal
b. Inhaled poisons
- Carry victim to fresh air immediately and loosen tight
clothing
- Remove foreign bodies from mouth, hold his chin up,
tilt his head back and ventilate
c. Skin contamination
- Drench skin with water
- Do not use chemical antidotes- their reaction would
give more heat (exothermic reaction)
d. Eye contamination
- Holding lids apart, wash the eye with water for 5 min
- Do not use chemical antidotes
e. Snake, insect bite
- Immobilize part immediately
- Apply bandage proximal to the bite site
- If patient must move, carry on stretcher
- Give specific anti-sera
f. Injected poison
- Apply tourniquet proximal to the injection site
1. Removal of Poison (Decontamination)
If poison is ingested the stomach should be emptied
as quickly as possible
Gastrointestinal decontamination
a. Adsorption- activated charcoal is effective for
adsorbing (elements bind to surface) almost all
poisons and not absorbing(soak up).
First line decontamination method.
 Dose
Adult and teenagers- 25-100gm mixed with water
Children1-12 years- 25-50gm or 0.5-1gm/kg body wt
Children up to1 year- 10-25gm or 0.5-1gm/kg
Preparation
50gm activated charcoal to 400ml distilled water and
shake well
The following substances are not adsorbed by activated
charcoal. The acronym PHAILS is used
• Pesticides
• Hydrocarbons
• Acids, alkalis, alcohol
• Iron
• Lithium
• solvents
b. Emesis- quickest and most effective way to
evacuate gastric contents
Indication- removal of poison in cooperative patients
Contraindication- drowsy/unconscious patient,
severely drunk, kerosene ingestion (danger of
aspiration), gasolene, fuel oil, paint thinner, ingestion
of corrosive poisons(caustics).
 Technique
Give an emetic- syrup ipecac?- it works by irritating the
stomach lining and stimulating the vomiting centre of
the brain
Dose- 10-15mls and repeat 15-30minutes if first dose is
not effective. Drink 1-2 glasses of water after taking it
c. Gastric aspiration/lavage
Indication- if vomiting cannot be induced/syr
ipecac not available, within 3 hr after poison has
been taken, non-corrosive poisons, CNS depressant
drugs, heavy metals, sustained release medicines, life
threatening massive ingestion, for administration of
antidotes
Contraindication- strong corrosive agents,
struggling/unconscious patient, kerosene or other
hydrocarbons
• Technique- pass an NG tube and aspirate with a
syringe; use physiological saline, 1% sodium
bicarbonate or plain water in small amounts at a
time and lavage 10-12 times or until the returns are
clear; as soon as lavage is complete introduce an
antidote if indicated (milk may be used as non-
specific antidote)
Surface decontamination
• Remove clothing and wash skin with soap and water
• Wash eyes with water or normal saline
2. Administration of specific antidotes
Antidote Main indication To be available within:

Acetylcysteine paracetamol 2 hours

Atropine Organophosphates 30 minutes

carbamates
Beta blockers Beta adrenergic agonists 30 minutes

Calcium gluconate Fluorides, oxalates 30 minutes

Deferoxamine iron 2 hours

Decobalt edetate, cyanide 30 minutes

hydroxocobalamin, sodium
nitrate, sodium sulfate
Antidote Main indication To be available within:

Ethanol methanol 30 minutes

Folinic acid Folinic acid antagonists 2 hours

Flumazenil benzodiazepines 2 hours

Glucagon Beta blockers 30 minutes

Glucose(hypertonic) insulin 30 minutes

Methylene blue methaemoglobinaemia 30 minutes

Antidote Main indication To be available within:

Naloxone opiates 30 minutes

Oxygen Carbon monoxide 30 minutes

Penicillamine copper 6 hours

Phentolamine Alpha adrenergic poisoning 30 minutes

Physostigmine atropine 30 minutes

Phytomenadione(Vit k1) Coumarin derivatives 6 hours

Protamine sulfate heparin 30 minutes

3. Supportive Therapy
In addition to specific methods for treatment of
acute poisoning , more general supportive treatment
are required
- Adequate airway should be maintained with
ventilation and provision of oxygen
- Maintain the circulatory status with IV fluids
4. Life-sustaining measures in severe poisoning
(Enhancement of excretion)
- Dialysis- haemodialysis- poisons that circulate in the
blood or reversibly bound to tissues or colloid are
removed by dialysis
- Forced diuresis- increase drug excretion
- exchange transfusion if poison tend to remain in the
circulation
- Sodium bicarbonate for alkalination of
urine(aspirin)
- Ammonium chloride for acidation of urine
 Snake Bite

Not all bites from poisonous snakes result in

envenomation. If no pain or swelling is present
within 30 minutes, injection of venom probably did
not occur.
Venom are complex mixtures of enzymes,
polypeptide toxins and other organic and inorganic
compounds.
 Classification of Snakes

Poisonous snakes are classified according to the type of venom

(toxin) they produce:
• Vasculotoxic/haemorrhagic (viper)
• Neurotoxic (cobra)
• Myotoxic (sea snake)
• Cytotoxic(viper)
• Cardiotoxic(viper)
The clinical manifestations may be divided into:
1. Local (at the site of bite)- pain and swelling of more than half
the bitten limb are common. The site of the bite may become
infected with abscess formation/necrosis, blistering and
bruising. Compartment syndrome may occur in the limbs
2. Systemic manifestation (the effect of toxaemia)-
these depend on the type of toxin.
• In the vasculotoxic/haemorrhagic- blood
coagulation becomes impaired and damage to the
lining of the capillary vessels. This results in
bleeding into the skin, bleeding gums, epistaxis,
injection sites and internal organs- hamatemesis
and malaena stools, haemoptysis and haematuria.
Snake responsible is the carpet viper
• In the neurotoxic- the toxin is neuroparalytic leading
to involvement of the diaphragm and the intercostal
muscles. There is weakness and laboured respiration.
There is dysphonia and dysphagia due to paralysis of
the laryngeal and pharyngeal muscles. Ptosis may
occur; faecal and urine incontinence may occur. The
snakes involved are the cobra and mamba
• The myotoxic is less common and involves
destruction of the muscles affected. Stiff painful
muscles and trismus. The sea snake is involved
• Cardiotoxicity- there is hypotension and arrythmias.
The snake involved is giant viper.
• Cytotoxicity- there is massive local swelling,
blistering, necrosis and extravasation of blood. The
snakes involved are the giant viper, carpet viper,
spitting cobra
 Treatment

Treatment include:
First Aid
• Spread of venom- is through the lymphatic system
and can be prevented by applying a pressure bandage
and not a tourniquet proximal to the wound and
splinting. Do not allow the patient to walk.
• Wound care- do not make cuts around the wound (it
has no proven value). Give tetanus prophylaxis,
antibiotics, clean wound with soap and water and
debride necrotic tissue, perform fasciotomy if there
is marked swelling.
• Pain relief- paracetamol but if severe give pethidine,
morphine 10mg stat IV/IM/sc
 Staging of Envenomation

• No envenomation
– No venom released, only fang mark(s)
• Mild envenomation
– Fang mark(s) + local tissue edema & necrosis
• Moderate envnomation
– Edema, bullae beyond immediate area +/-clinical /
lab evidence of systemic effect
• Severe envenomation
– Edema, bullae on entire limb, bite on head & neck
thorax, shock, ↓consciousness; + lab
 Indication for Antivenom

• Severe local envenoming:

– swelling involving more than half the bitten limb
or develop extensive blistering
• Systemic envenoming
– Haemotoxicity
– Neurotoxicity
– Cardiotoxicity
– Myotoxicity etc
• Impaired consciousness
• Local envenoming however small it may be
plus
– vomiting in the absence of emetic mixture (herbal
or orthodox) ingestion
– neutrophil leucocytosis
– elevated serum enzymes (CPK & AST)
– haemoconcerntration (elevated PCV)
– Uraemia
– oliguria ( urine output <0.5ml/kg/hour )
• Confirmed case of elapid (cobra, mamba)
– do not wait for symptoms
– evidence of fang penetration and snake must
definitely have been an elapid
 Administration of Antivenom

• Give correct anti-venom: give polyvalent if in doubt

but if snake species is known give the specific
monovalent.
- Starting dose- not less than 40mls. Doses are the
same for adults and children. Ideally, dilute
antivenom in equal volume of saline and give by IV
infusion(drip) over 1 hr or IV injection not faster than
10mls in 5 minutes. Repeat doses until effect of
venom is neutralized.
• Dosage
• 40ml in 200ml Normal saline IV stat, for adder/viper
bite
• 60-80ml in 200ml Normal saline IV stat, for elapid
(neurotoxin) bite
• Run few drops initially as “Test dose”(0.2mls sc with
adrenaline 1:1000 ready for resuscitation) for serum
sensitivity and look out for reaction, if no reaction
then whole drip in 1hr.
• Repeat dose of antivenom if signs &
symptoms of envenoming persist after
1st dose
– Persistence of cardiopulmonary signs > 30min
after 1st dose
– Persistence of incoaguable blood > 6hrs after 1st
dose
• Have adrenaline drawn up prior to giving
antivenom +drugs for anaphylaxis e.g
antihistamine, steroid
• Counteract effects of venom
- Respiratory muscle paralysis- artificial ventilation
- Haemorrhagic shock- transfuse fresh whole blood
- Snake spit into eye- irrigate with large amounts of
water/any liquid or dilute ASS 1 part in 5 parts N/S
and irrigate then treat as corneal abrasion (eye pad
and topical antibiotic)
• Prevent secondary infection-Give penicillins plus
metronidazole and tetanus prophylaxis.
 Late Antivenom Reaction(Serum Reaction)

• It is a type of delayed allergic response, appearing 4-

10 days after exposure to antitoxin. The patient
immune system recognizes the protein in the
antitoxin as foreign proteins and produces its own
antibodies to protect against the foreign proteins.
The antibodies bind with the foreign proteins to form
complexes. These immune complexes enter the walls
of the blood vessels where they set of an
inflammatory reaction leading to the following
symptoms:
• Severe skin reaction of the palms and soles
• Fever, joint pains
• Lymphadenopathy, swelling of neck and head
• Difficulty breathing
Treatment
• Discontinue antitoxin
• Give antihistamines +/- corticosteroids
• Give pain killers
 4. Animal bite- Rabies

Rabies is caused by the rabies virus of the family

rhabdoviridae through a rabid animal bite.
Transmission- by contamination of wound/mucous
membranes with saliva from a rabid animal
Prevention – with post-exposure prophylaxis
Pathophysiology- after innoculation the virus infects
and multiplies in striated muscle cells
Virus eventually attaches to the nerve, ascends along
axons to the spinal cord. Paresthesia may begin at
the wound site and continues to spread throughout
the CNS. Subsequently along peripheral nerves to the
skin, intestines and salivary glands. Incubation period
is 5 days – 1year.
Clinical Features
• History of animal bite
• Nonspecific fever and pharyngitis
• Pain/paresthesia at the site of bite
• Hydrophobia- sight of water provokes terror
• Aerophobia- current of air across face causes violent
spasms of pharyngeal and neck muscles
• Paralysis usually develops
• Late symptoms- hypotension, coma, DIC, cardiac
arhythmias, cardiac arrest
Treatment- no specific treatment available
- intensive supportive care
 Post-exposure Management

• Treat laceration / punctured wound

– Thorough irrigation
• Prevent rabies infection
– Wash site of animal bite with soap & water
– Thorough irrigation with saline/ appropriate fluid
– ± Rabies vaccine, and HRIG ( If indicated)
• Prevent other infection
– Thorough irrigation, local wound care, antibiotics-
flucloxacillin and amoxicillin
• Tetanus immunisation update
 Indications for Post-exposure Management

• If
– Animal Normal at time of attack, and
– Animal Normal after 10days observation
 No vaccination, No HRIG
• If
– Animal Normal at time of attack, but
– Confirm signs of rabies 10 days observation
 Initiate vaccination @ 1st sign animal rabies
 Give HRIG 20 IU/Kg (10 IU/kg +10 IU/Kg)
• If condition of animal
– Strong suspicion of rabies at time of attack
(e.g. unprovoked attack, etc) with
– Unconfirmed sign of rabies during observation
– Unprovoked bite with penetration of skin
Initiate vaccination, (days 0, 3, 7, 14, 28)
 stop if animal normal on day 5
 continue if rabies confirmed / suspected
 Give HRIG 20 IU/Kg (10 IU/kg +10 IU/Kg)
• If
– Rabid animal at time of attack
– Or unable to confirm status of animal*
Initiate vaccination immediately
Give HRIG 20 IU/Kg (10 IU/kg +10 IU/Kg)
NB: an immunized dog is protected for one year
• Vaccine takes 7-10 days to induce active immune
response, lasting approximately 2-3 yrs.
• Administer vaccine in the deltoid region, with a dose
of 1 mL on days 0, 3, 7, 14, & 28
• Slight erythema may be expected at injection site
• For young children, outer aspect of the thigh may be
used for injection.
• Do not administer in the gluteal area because of poor
response
• Passive immunization with human rabies
immune globulin (HRIG) provides immediate
protection of 21 days.
• Administer HRIG @20 IU/kg
– 10 IU/Kg infiltrated in and around the wound (if
wound location allows)
– 10 IU/Kg IM in the gluteal region, using a needle
long enough to ensure an IM injection
• The syringes & needles used for vaccine &
immune globulin should be different
• HRIG
– Through an antigen-antibody antagonism, may
diminish antibody response to measles, mumps,
and rubella vaccine
• Rabies Vaccine
– Antimalarials (esp. CHQ), Corticosteroids, and
other immunosuppressive agents may reduce
protective efficacy of vaccine
 5. Scorpion Sting

• The less dangerous ones cause severe local pain and

minor swelling
• The dangerous species contain a powerful neurotoxin
which stimulates postganglionic fibres of the
autonomic nervous system and has direct action on
muscle, including myocardium
Symptoms may improve after a few hours and then
relapse
Treatment- pain can be relieved by injecting 1-2%
lignocaine locally
- systemic symptoms indicate the need for specific
antisera, antihistamine
 6. Bee and Wasp Sting

They produce localised pain and swelling. They may

occasionally cause allergic reactions leading to
anaphylaxis with generalized urticaria, hypotension and
difficulty in breathing
Treatment
• Adrenaline 1:1000 sc 0.5-1ml stat
• Promethazine 50mg IM stat
• Hydrocortisone 100-200mg IV , repeat after 6 hours
• IV fluids if shock
• Paracetamol 500-1000mg 6-8 hourly
 7. Unconsciousness

There are various states of altered consciousness which

are graded clinically as:
Grade1 Mild confusion- altered mood or behaviour,
drowsy, disoriented. The patient responds to simple
commands and to his name
Grade 2 Stupor-the patient reacts to painful stimuli in a
purposeful manner eg he will use his hand to try and
remove the stimulus
Grade 3 Semiconscious-reacts to painful stimuli in a
non-purposeful manner eg he is able only to groan
Grade 4 Deep unconsciousness (coma)-there is
absolutely no response to painful stimuli

Causes
1) Brain Disorder
a) Infections-meningitis, encephalitis, cerebral abscess,
cerebral malaria
b) Trauma/Accident-head injury, subdural haematoma,
CVA
C) Tumour- brain tumours
2) Metabolic-diabetes mellitus
-hyperglycaemia
-hypoglycaemia
3) Organ failure
-hepatic failure -cardiac failure
-renal failure -respiratory failure
4) Poisoning
-organophosphate
-drug (salicylate overdose)
-alcohol

Basic Investigation
-FBS, urine sugar
-Blood for malarial parasites
-Blood urea , electrolytes
-Lumbar puncture but not in raised intracranial
pressure
-CT scan for space occupying lesions
- LFTs
- Blood/urine culture
 Clinical Features

General Signs Possible Diagnosis

Fever Meningitis, cerebral malaria
Jaundice Malaria, hepatic encephalopathy
Dehydration Diabetic coma
Ketotic breath Diabetic ketoacidosis (DKA)
Acidotic breathing DKA, Renal failure
Hypersalivation Organophosphate poisoning(DDT)
Sweating Hypoglycaemia
Petechial haemorrhages Septicaemia
Neurological Signs Possible Diagnosis
Constricted pupils Drug overdose
(morphine/heroin),
organophosphate poisoning
Neck stiffness Meningitis, subarachnoid
haemorrhage
Hemiplegia/paresis CVA, Subdural haematoma
Muscle fasciculation Organophosphate poisoning
Fluctuating consciousness Subdural haematoma
Papilloedema Primary brain disorder
Cardiovascular Signs Possible Diagnosis
Raised BP CVA, HPT encephalopathy, renal
failure
Bradycardia Organophosphate poisoning
Heart murmurs Cerebral embolus

Abdominal Signs
Hepatosplenomegaly Cirrhosis with hepatic failure
and
encephalopathy
 Care of the Unconscious Patient

1) Maintain clear airway

• Put in recovery position
• Insert an oral airway
• Give 100% oxygen
• Suck frequently
2) Prevent development of pressure sores
-two hourly turning and recording
3) Ensure bladder drainage-insert indwelling catheter
4) Ensure bowel emptying-enema every 2-3 days
5) Ensure adequate hydration and nutrition
-IV infusion of normal saline or dextrose water for the
first 24hours (1litreN/S, 2litres D5%)
-then commence NG tube feeding
6) Prevent muscle contractures-do physiotherapy
7) All unconscious patients must be intensively
monitored and should include:
• Pulse rate
• Blood pressure
• Respiratory rate
• Conscious level as already discussed ie Grade 1-4
These observations should be chartered at regular
intervals (1/4,1/2,1,2 hourly etc) depending on the
condition
8) Treat the cause.
 8. Convulsion

Convulsion are motor signs of abnormal electrical discharges

in the brain.
Causes
o Epilepsy
o Eclampsia
o Febrile convulsion in children
o Meningitis
o Cerebral irritation from hypoxia
o Hypoglycaemia
o HIV
o Cerebral malaria
o Alcohol withdrawal
o Intracranial lesion
o Encephalopathy
o Drug poisoning or overdose eg local anaesthetic
Consequences
 Breath- holding leading to hypoxia
 Collapse
 Biting of tongue
 Vomiting and aspiration
 Other physical injury
 Treatment
• Set up IV line
• Bolus diazepam 10mg IV, repeat 1 or 2 hourly.
Diazepam 10mg rectally is safe for children
• Urgently look for and treat the cause of convulsion
• Intubation and ventilation if respiration has ceased
 9. Epilepsy

Epileptic seizures are abnormal synchronous activity of groups of neurons in the brain
characterized by spontaneous recurrent seizures.
A number of potential mechanisms contribute to epilepsy- some genetically and some
acquired.
a. Genetic- congenital
b. Acquired
• Injury- prenatal, perinatal
• Cerebral malaria
• Febrile illness between age 6months- 6 years
• Infections- meningitis, brain abscess, TB/HIV
• Vascular disease-HPT encephalopathy, stroke
• Trauma- head injury
• Space occupying lesion- tumour
• Degenerative disease- dementia
• Metabolic- hypoglycaemia, hepatic failure, renal failure with uraemia
• Drugs- alcohol/withdrawal, metronidazole, antidepressants
• Eclampsia
Signs and Symptoms
• Loss of consciousness
• Foaming at the mouth
• Tongue biting
• Incontinence of stool/urine
• Sleeping for some time after the seizure
• Aura prior to seizure which may be- visual, auditory,
smell
• Tonic stage(body rigid), clonic stage(jerking
movements of limbs, trunk and facial muscles)
Epilepsy can be classified into:
1. Partial seizures(arise focally within the brain with
variable spread)
• Simple partial seizures- consciousness not impaired.
There may be motor signs or special sensory
symptoms
• Complex partial seizures- impairment of
consciousness. They may be followed by automatic
behaviour of which the patient has no recall.
• Partial seizures evolving to generalized tonic-clonic
seizures.
2. Generalized seizures(widespread bilateral epileptic activity
from the onset)
• Absence seizures(petit mal)- patient becomes unresponsive
for a few seconds with rapid recovery
• Myoclonic seizures- brief jerks of one or more limbs
• Clonic seizures-repetitive jerking of limbs and trunk
• Tonic seizures- tonic contraction of muscles causing flexion or
hyperextension of the trunk
• Tonic clonic seizures(Grand mal seizures)- tonic followed by
clonic phases which may be associated with salivation, tongue
biting, incontinence of urine/faeces, then sleep
• Atonic seizures- brief loss of muscle tone
3. Unclassified epileptic seizures
4. Status epilepticus
When a series of seizures occur without the patient
regaining consciousness between attacks for more
than 5 minutes or seizures lasting for more than 30
minutes
 Differential Diagnosis
• Syncope
• Hypoglycaemia
• Transient ischaemic attack
• Parasomias- sleep walking , sleep talking

Diagnosis
• Is essentially based on an adequate history including
observed convulsions, biting the tongue, incontinence,
unconsciuosness and slow recovery
• EEG rarely diagnose epilepsy
Investigation
- FBC, FBS, BUE, LFT’s
- CT scan is essential if there are focal lesions. It is
however normal in the majority of patients
Treatment
1. Generalized seizure
• Tab phenobarbitone 60-180mg nocte daily OR
• Tab phenytoin 100mg 6-8 hourly prn OR
• Carbamazepine100-200mg bd OR
• Sodium valproate 600-2000mg 2-3 times daily. NB
used for petit mal
2. Partial seizure
• Sodium valproate 600-2000mg 2-3 times daily
• Carbamazepine 100-200mg bd
3. Status epilepticus- IV diazepam or IV
phenobarbitone (10-20mg/kg, repeat after 20mins,
max 30mg/kg). If after 1 hr the seizures are not
controlled contact anaesthetist for GA and ventilate
or refer

Treatment can be stopped after 2 years free of

seizures.
Advise to epileptic patients
• Do not drive
• Do not swim
• Do not work at heights
• Do not operate machines
• Do not cook by open fire alone
• Do not drink excessive alcohol
 10. Asphyxia

Is a life-threatening condition where the body does not

get enough oxygen to the tissues to continue normal
function. Without adequate oxygen nerve cells in the
brain begin to die in about 2-4 minutes and cell death is
irreversible.
Causes
Asphyxia occur when the airway is physically blocked, or
as a side effect of an injury or other medical condition
• Physical blockade
Choking, foreign body in respiratory system or throat,
suffocation, strangulation, drowning, tongue falling back
• Injuries or illness
Lung collapse, inhalation of toxic fumes(carbon monoxide),
whooping cough, diptheria, croup, heart failure, asthma,
allergic reaction, drug overdose, sleep apnoea
Symptoms
• Difficulty in breathing
• Rapid pulse
• Increase BP
• Cyanosis
• Convulsions
• Paralysis
Treatment
• First aid to remove foreign body
• CPR
• Treat identified cause
 11. Drowning

Defined as a process of experiencing respiratory

impairment from submersion or immersion in liquid.
Drowning is classified based on victim outcome:
• Died
• Survived with no impairment
• Survived with some physical or mental impairment
Causes
• Infants often drown in a bathtub
• Children most often drown in a neighbourhood or
backyard pool
• Teens and young adults tend to drown in natural water
bodies(rivers, lakes)
Contributing Factors
• Alcohol
• Trauma- broken neck from diving into shallow water
• Medical emergencies- seizures, heart attack
NOTE
• Drowning is a panick experience
• If water comes into contact with the vocal cords they
go into spasm and prevent the victim from shouting
for help
• Watch for anyone who seems to be swimming
ineffectively
Diagnosis
• Based on history
• Victim found struggling in water and most often have
difficulty in breathing
• Any person who has breathing compromised and has been
immersed in water can be said to be drowned
Treatment
• First recognize that the victim is in trouble
• Assess whether they are awake and breathing
• If victim is not breathing on their own or breathing
ineffectively , then rescue breathing should be administered
• If there is no heart beat , then start CPR
Prevention
• Learn how to swim
• Don’t swim alone
• Never leave infants alone in bathtub or sink
• Supervise children when near water
• Swimming pools should be fenced with locked gates
and inaccessible to unsupervised kids
• Alcohol should be consumed in moderation when
swimming or in a boat
• Water floating devices should always be used during
activities on the water
 12. Bandages and Bandaging

A bandage is a piece of material used either to

support a medical device such as a dressing or splint,
or on its own to provide support to or to restrict the
movement of a part of the body
Uses
• To prevent contamination of wound by holding
dressings in position
• To provide support to the part that is injured,
dislocated
• To provide rest to the part that is injured
• To prevent and control haemorrhage
• To restrict movement/immobilize a fracture or a
dislocation
• To correct deformity
• To maintain pressure eg elastic bandage
Types of Bandages
• Elastic bandage
• Adhesive zinc-oxide bandage
• Gauze packs and rolls
• Triangular bandage
• Suspensory bandage
• Gauze bandage with plaster cast material
• Roller bandage
• Four-tailed bandage
Gauze pads and Rolls- have the ability to hold the injury
after it is dressed. Because of this the injured area is
held firm irrespective of the part of the body. Can be
used for open wounds and abrasions
Triangular bandage- more commonly used to secure
dressing at one place especially when the dressing is
large because they are folded in triangular shape.
 1
They are also used as slings to support a limb or secure a
dressing in place. If you are using a triangular bandage as a
sling on an arm, you use it opened out. You should:
- Ask the person to hold their arm across their chest and
support the arm while you work
- Put the bandage under the arm and around the back of the
neck
- Put the other half of the bandage over the arm to meet at
the shoulder and tie into a knot
- Tuck the loose ends of the bandage in at the elbow, or use a
pin
• Adhesive bandage- used for supporting weakened joints such as knees,
ankles. Being stretchable it can easily adapt to any type of body contour
• Tubular bandage-especially meant for dressing on injured joints and
fingers and toes. Before placing a tubular bandage over an injury, you
may need to cut it to a smaller size
• Roller bandages- are so designed that they stretch to a small extent. It
gets well adjusted to the shape of the injured part and contours, keeping
the dressing right at the place. Narrower width roller bandages are used
for toes and fingers. Roller bandages are of 3 types:
- Bandages made of open weave material allow ventilation but don’t put
pressure on wound and don’t support joints
- Elasticated bandages mould to a persons body shape, and are
 used to secure dressings and support soft tissue injuries like sprains
- Crepe bandages are used to give firm support to injured joints
To apply roller bandage
- Keep the unrolled part of the bandage above the injury and the
rolled part below the injury
- Begin by wrapping twice around the injury to hold the end in place
- Work up the limb, winding the bandage in spiralling turns, making
sure that each new layer covers 1/3- 2/3 of the previous one
- Finish wrapping the bandage around once more and secure the end
 How to apply a bandage- key points
• Make sure the person is comfortable and tell them what you
are doing
• Work from the side of the injury so you do not have to lean
across their body
• Keep the injured part of the body supported in the position
it will be in when the bandage is on
• Use the right size bandage- different parts of the body need
different widths of bandage
• Avoid covering fingers or toes when bandaging a limb so you
can easily check the circulation
• Apply the bandage firmly, but not tightly, and secure
the end by folding it over and tying a knot in the end.
You can also use a safety pin, tape or bandage clip
• As soon as the bandage is on, ask if it feels too tight
and check the circulation by pressing on the
fingernail or a piece of skin until it turns pale. If the
colour doesn’t return straight away, the bandage may
be too tight, so you should loosen it. Limbs can swell
up after injury, so check the circulation every 10
minutes after you have put the bandage on
 Size of bandage
Bandage vary according to the part it is supposed to
bandage
PART WIDTH(CM) LENGTH(MTS)
Head 5 4-6
Trunk 10-15 6-8
Leg 6-8 4
Arm 5-6 3-4
Fingers 2.5 2
Hand 5 3
Wrist 5 3
 How to apply different types of Bandages
1. Applying a strip bandage- are ideal for covering
small cuts and minor wounds on hands and finger.
Make sure the padded gauze part of the bandage is
larger than the wound itself. Place the padded
gauze section of the bandage directly over the
wound. Gently stretch the adhesive tape part of the
bandage and attach it firmly to the skin surrounding
the wound
2. Applying a wrap/Elastic bandage- they are ideal for
larger wounds on the extremities.
You need to apply a sterile gauze to the wound itself
before applying the bandage. You need to fasten the
bandage after application with clips or tape to hold the
end of the bandage in place
3. The Basics of Bandaging
• Understand the purpose of a bandage
• Avoid bandaging too tightly
• Use a bandage for breaks and dislocations
• Know when to seek medical attention
- if bandage wound has not begun to heal or causes
significant pain after 24 hours
- If wound larger than 3cm, has lost skin or involves
underlying tissues
• Clean and treat wounds prior to bandaging
4. Bandaging a minor cut
• Use a strap bandage for minor cuts
• Use a knuckle bandage for finger and toe wounds. It
is a special bandage shaped like an H making it easy
to apply between fingers and toes
• Use gauze and adhesive bandage to bandage a burn
• Use moleskin to bandage a blister. It is a special type
of foam-adhesive bandage used to prevent a blister
from being rubbed. It is doughnut shaped with a cut-
out in the centre for placement over the blister
5. Bandaging serious wounds
• Use pressure bandage- used to prevent heavy
bleeding
• Use doughnut bandage- used for wounds that
contain foreign body
• Use triangular bandage- to secure a dislocated or
broken bone
• Use gauze rolls- to bandage second degree burns
• Use a tensor bandage on a deep cut or accidental
amputation. They are made of thick elastic that help
to apply heavy pressure to severe bleeding