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Welcome to. Emergency Medicine 2009. Introduction Review of Course Syllabus The Emergency Department Legal Issues In Emergency Medicine Approach to the ED patient Shock/Patient Resuscitation. The Emergency Department. Function of the ED Problems faced by most ED’s The Successful ED.

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  1. Welcometo Emergency Medicine 2009

  2. Introduction Review of Course Syllabus The Emergency Department Legal Issues In Emergency Medicine Approach to the ED patient Shock/Patient Resuscitation

  3. The Emergency Department Function of the ED Problems faced by most ED’s The Successful ED

  4. Function of the ED • Triage -sorting of patients into groups according to priority for treatment using: Severity of illness Prognosis Availability of resources • Prioritize • Stabilize • Observe • Disposition • Refer

  5. Problems faced by most ED’s • Patients with lack of adequate medical insurance. • Nursing shortages. • Lack of hospital beds • HIV/AIDS, crack cocaine and other substances. • Street violence. • STD epidemic • The threat of malpractice litigation. • Overwhelmed community social and other non-medical resources.

  6. The successful ED • Control over patient intake. • Control of the ED environment. • Control of patient-care events. -patient flow organization -equipment -policies and procedures • Ability to control disposition resources.

  7. Legal IssuesinEmergency Medicine

  8. Legal Issues in Emergency Medicine • Good Samaritan Acts • COBRA • EMTALA • Disclosure of confidential medical information • Negligence • Abandonment • Consent and refusal of consent • Reporting laws • Resuscitation decisions • Advance directivies

  9. Legal Issues in Emergency MedicineGOOD SAMARITAN ACTS Division 2.5 of the California Health and Safety Code: 1799.102. No person who in good faith, and not for compensation, renders emergency care at the scene of an emergency shall be liable for any civil damages resulting from any act or omission. The scene of an emergency shall not include emergency departments and other places where medical care is usually offered

  10. Legal Issues in Emergency MedicineFederal Screening and Transfer laws • Comprehensive Omnibus Reconciliation Act (COBRA) -Enacted by congress to combat widespread patient dumping. • Emergency Medical Treatment and Active Labor Act (EMTALA): -This is the section of COBRA that applies to ED’s.

  11. Legal Issues in Emergency MedicineFederal Screening and Transfer Laws • EMTALA - requires hospitals and ambulance services to provide care to anyone needing emergency treatment regardless of citizenship, legal status or ability to pay. As a result of the act, patients can be d/c’d only under their own informed consent or when their condition requires transfer to a hospital better equipped to administer the treatment.

  12. Legal Issues in Emergency MedicineHIPAA • Health Insurance Portability and Accountability Act (HIPAA) -addresses the use and disclosure of individuals’ health information called “protected health information” by organizations subject to privacy rule—as well as standards for individuals’ privacy rights to understand and control how their health information is used.

  13. Legal Issues in Emergency MedicineDisclosure of confidential information • Medical Records -Medical providers, nurses and other hospital personnel have access only on a need to know basis. -Police do not have a right to a patient’s medical information without a subpoena. -IRS is authorized access to medical records without subpoena. -Spouses and family members generally do not have a right to other adult family member’s records. -Insurance interests only have a right to access patients’ records with signed releases.

  14. Legal Issues in Emergency MedicineNegligence • Negligence is defined as the omission to do something that a reasonable practitioner, guided by those ordinary considerations that ordinarily regulate human affairs, would do, or the doing of something that a reasonable and prudent practitioner would not do.

  15. Legal Issues in Emergency MedicineNegligence • Negligence consists of four components: • Duty • Breach of duty • Damages • Causation All four must exist in order to be found negligent.

  16. Legal Issues in Emergency MedicineConsent • Express consent entails an awareness of the proposed care and an overt agreement (oral or written) to proceed. • Implied consent is invoked if an emergency exists and the patient is incompetent (a minor or someone with an altered status) • Informed consent (written) the patient knows and understands the risks, benefits, and consequences of accepting or refusing treatment. • Emergency consent bypasses normal consent standards, implied consent is inferred by the patient’s actions, but without specific aggreement. • Failure to obtain appropriate consent can lead to legal action based on battery(intentional unauthorized touching)

  17. Legal Issues in Emergency MedicineRefusal of consent • Adult patients my ethically and legally refuse treatment totally or in part. • Informed refusal should be carefully documented on the chart of a patient who leaves against medical advice (AMA) • There are five components that should be addressed in the chart. -Capacity -Discussion -Offer of alternative treatment -Family Involvement -Patient’s Signature

  18. Legal Issues in Emergency MedicineMinors and Consent • The law always implies consent for treatment of a child in the event of an emergency. -Parental consent is not needed—it is implied. • All states without a general consent statute for minors have provision that specifically permit the physician to treat any minor for venereal disease • Most states have treatment statutes for minors, which enable them to consent for medical care. Many states also specifically permit treatment of minors for drug or alcohol problems, pregnancy, and psychiatric conditions. • Mature minor usually 14-18yrs old allow a minor to give informed consent. Generally applies to treatment that do not pose a serious risk.

  19. Legal Issues in Emergency MedicineAdvance Directives/ Resuscitation Decisions • Do Not Resuscitate (DNR) • Living Wills • Durable Power of Attorney

  20. Legal Issues in Emergency MedicineReporting Laws • Reportable Events -Communicable Diseases Gonorrhea, Syphilis, HIV/AIDS, etc... • Violent Acts -Child and elder abuse -Spousal abuse -Sexual Assault -Stabbings and shootings. • Deaths

  21. Legal Issues in Emergency MedicineMedical Ethics • There are five basic principles that should guide ethical decision making in medical practice. -Veracity -Patient autonomy -Beneficence -Nonmaleficence -Justice

  22. Approach to the EDPatient

  23. Patient Assessment • Primary assessment • Secondary assessment

  24. Primary Assessment • Goal of Identifying and treating life-threatening conditions. • A,B,C,D,E’s

  25. Primary Assessment • A irway maintenance with C-spine precautions • B reathing/ventilation • C irculation with hemorrhage control • Disability GCS (pg553) -Neurologic disability level of consciousness mental status pupil size and reaction • E xposure -completely undressed patient for thorough assessment

  26. Secondary Assessment • Purpose • to identify as many injuries as possible • Perform thorough head-to-toe evaluation of patient.

  27. Shock /Patient Resuscitation

  28. Shock • Shock- -circulatory insufficency -creates an imbalance between tissue oxygen supply and demand resulting in an oxygen debt.

  29. Pathophysiology • Normally, 25% of the oxygen carried by the Hb is consumed by tissues • Venous blood returning to the R heart is 75% saturated. • When O2 supply is insufficient to meet demand, 1st compensatory mechanism is to increase cardiac output • If increase in cardiac output is insufficient, amout of O2 extracted from Hb increases

  30. Pathophysiology • When compensatory mechanisms fail, anaerobic metabolism results in formation of lactic acidosis • Most cases of lactic acidosis result from -inadequate O2 delivery (Cardiogenic shock) -Can result from excessively high O2 demand (status epilepticus)

  31. Pathophysiology • Shock is usually but not always associated with arterial hypotension: SBP<90mmhg • MAP= CO X SVR • SBP is not the best indicator of tissue perfusion • Shock can occur with a normal BP and hypotension can occur without shock

  32. Pathophysiology • Onset of shock stimulates the ANS baroceptors in the aortic arch and carotid bodies activates the SNS leading to: -arteriolar vasoconstriction -increased HR and contractility -release of vasoactive hormones (Epi, Ne..) -release of ADH and activiation of RAA

  33. Pathophysiology • Delivery of oxygen to the brain and heart takes priority!!!!

  34. Pathophysiology • At the cellular level: -ATP depletion results in ion-pump dysfxn -Influx Na -Efflux of K -Reduction in resting membrane potential -Cellular edema and loss of cellular integrity -Hyperkalemia, hyponatremia, metabolic acidosis, hyperglycemiaand lactic acidosis

  35. Etiologies • Shock can be classified into 4 major types -Hypovolemic -Cardiogenic -Obstructive -Distributive -Combination

  36. Etiologies • Hypovolemic Associated with decreased preload which could be due to: Hemorrhage: -Overt in GI bleeding or trauma -Concealed such as aortic aneurysm rupture, retroperitoneal bleeding, long-bone fractures or traumatic cavity bleeds, malignancies, ectopic pregnancy, ruptured ovarian cyst. Fluid depletion: -GI losses such as diarrhea, vomiting -Insensible losses, e.g., burns -Third space losses, e.g., major surgery, pancreatitis, intestinal obstruction Decreased preload results in a decreased cardiac output with diversion of blood from the splanchnic circulation to vital organs thus increasing the SVR

  37. History & Physical Exam • Refer to handout

  38. Diagnostic Tests CBC, serum chemistries, serum ammonia level, Bhcg, PT, PTT, INR, amylase, LFTs, trial of fluids, FAST scan, x-ray trauma series, x-ray of affected limb, abdominal x-ray, U/S CT abdomen, CT angiogram,

  39. Treatment of Hypovolemic/Hemorrhagic Shock • Infusion of 1L crystalloid • Infusion of 1L PRBC • Fluid resuscitation -Isotonic crystalloid with NS or LR NS or LR requires a volume approximately 3x that lost. • Blood transfusion -Cross-matched blood -Type-specific blood -Type-O blood

  40. Etiologies • Cardiogenic Results from heart pump dysfunction (more commonly left-sided) causing a decrease in cardiac output in the setting of increased preload. The compensatory surges in catecholamines lead to increased SVR. However, in some instances (esp Acute Coronary Syndrome), decreased SVR may be observed. Early, aggressive management can lead to improved outcome. Myocardial infarction, viral and alcoholic cardiomyopathies, CHF and cardiac valvular lesions are some of he main contributors massive pulmonary embolism.

  41. History & Physical Exam • Myocardial infarction -chest pain, radiation to L arm, history of exertional chest pain; smoking, hypercholesterolemia, FHx; DM; high BP -signs of heart failure; jugular venous distention, basalilar crackles on lung auscultation; heart murmur

  42. Diagnostic Tests • Diagnosis should be suspected from the initial HX & Physical exam. • Ancillary tests are needed to confirm DX. -EKG, CXR, 2-dimensional transthoracic echo, lab studies (cardiac enzymes, coagulation parameters, serum lactate, and chemistries)

  43. Treatment of Cardiogenic Shock • ABCs • Oxygen • Cardiac monitor • Pulse Ox • Fluids (for Rv infarct) only • Pain control with NTG and morphine sulfate • Aspirin • If hypotensive after adequate fluid resuscitation consider dobutamine and/or dopamine for inotropic and pressor support • Reperfusion modalities • Cardiology and/or thoracic surgery should be consulted early

  44. Etiologies • Obstructive Secondary to an obstruction to cardiac flow or filing: -Flow restriction; severe pulmonary HTN. Usually accompanies by decreased oxygenation with very minimal physical signs. -Filling restriction; cardiac tamponade or tension pneumothorax.

  45. History & Physical Exam • Tension pneumothorax -Sudden onset, often pleuritic, chest pain; SOB; rapid deterioration; recent placement of CVP line; history of emphysema; chest trauma -Absent unilateral breath sounds on the affected side; trachea deviated to the opposite side; hyper-resonance to percussion on affected side.

  46. Diagnostic Tests • Diagnostic and therapeutic needle thoracostomy • CXR before and after decompression

  47. Treatment of Obstructive Shock • Immediate needle thoracostomy • Maintenance of adequate ventilation • Pain control • Adequate pulmonary toilet (attempts to clear mucus secretions from the trachea and bronchial tree by deep breathing, incentive spiratomy, postural drainage and percussion.

  48. History & Physical Exam • Cardiac Tamponade -recent cardiac surgery or angiogram/plasty; chest trauma; malignancy; pericarditis, increasing SOB on minimal exertion. -Muffled heart sounds, low BP, jugular venous distention (beck’s triad); pulsus paradoxus

  49. Diagnostic Tests • ECHO

  50. Treatment of Obstructive Shock • Fluid replacement • Pericardiocentesis • Thoracotomy

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