Emergency medicine known as accident and emergency medicine, is the medical specialty concerned with the care of illnesses or injuries requiring immediate medical attention. Emergency physicians care for undifferentiated patients of all ages; as first-line providers, their primary responsibility is to initiate resuscitation and stabilization and to start investigations and interventions to diagnose and treat illnesses in the acute phase. Emergency physicians practice in hospital emergency departments, pre-hospital settings via emergency medical services, intensive care units, but may work in primary care settings such as urgent care clinics. Sub-specializations of emergency medicine include disaster medicine, medical toxicology, critical care medicine, hyperbaric medicine, sports medicine, palliative care, or aerospace medicine. Different models for emergency medicine exist internationally. In countries following the Anglo-American model, emergency medicine was the domain of surgeons, general practitioners, other generalist physicians, but in recent decades it has become recognised as a speciality in its own right with its own training programmes and academic posts, the specialty is now a popular choice among medical students and newly qualified medical practitioners.
By contrast, in countries following the Franco-German model, the speciality does not exist and emergency medical care is instead provided directly by anesthesiologists, specialists in internal medicine, cardiologists or neurologists as appropriate. In developing countries, emergency medicine is still evolving and international emergency medicine programs offer hope of improving basic emergency care where resources are limited. Emergency Medicine is a medical specialty—a field of practice based on the knowledge and skills required for the prevention and management of acute and urgent aspects of illness and injury affecting patients of all age groups with a full spectrum of undifferentiated physical and behavioral disorders, it further encompasses an understanding of the development of pre-hospital and in-hospital emergency medical systems and the skills necessary for this development. The field of emergency medicine encompasses care involving the acute care of internal medical and surgical conditions.
In many modern emergency departments, emergency physicians are tasked with seeing a large number of patients, treating their illnesses and arranging for disposition—either admitting them to the hospital or releasing them after treatment as necessary. They provide episodic primary care to patients during off hours and for those who do not have primary care providers. Most patients present to emergency departments with low-acuity conditions, but a small proportion will be critically ill or injured. Therefore, the emergency physician requires a broad field of knowledge and procedural skills including surgical procedures, trauma resuscitation, advanced cardiac life support and advanced airway management, they must have some of the core skills from many medical specialities—the ability to resuscitate a patient, manage a difficult airway, suture a complex laceration, set a fractured bone or dislocated joint, treat a heart attack, manage strokes, work-up a pregnant patient with vaginal bleeding, control a patient with mania, stop a severe nosebleed, place a chest tube, conduct and interpret x-rays and ultrasounds.
This generalist approach can obviate barrier-to-care issues seen in systems without specialists in emergency medicine, where patients requiring immediate attention are instead managed from the outset by speciality doctors such as surgeons or internal physicians. However, this may lead to barriers through acute and critical care specialties disconnecting from emergency care. Emergency medicine can be distinguished from urgent care, which refers to immediate healthcare for less emergent medical issues, but there is obvious overlap and many emergency physicians work in urgent care settings. Emergency medicine includes many aspects of acute primary care, shares with family medicine the uniqueness of seeing all patients regardless of age, gender or organ system; the emergency physician workforce includes many competent physicians who trained in other specialties. Physicians specializing in emergency medicine can enter fellowships to receive credentials in subspecialties such as palliative care, critical-care medicine, medical toxicology, wilderness medicine, pediatric emergency medicine, sports medicine, disaster medicine, tactical medicine, pain medicine, pre-hospital emergency medicine, or undersea and hyperbaric medicine.
The practice of emergency medicine is quite different in rural areas where there are far fewer other specialties and healthcare resources. In these areas, family physicians with additional skills in emergency medicine staff emergency departments. Rural emergency physicians may be the only health care providers in the community, require skills that include primary care and obstetrics. Patterns vary by region. In the United States, the employment arrangement of emergency physician practices are either private, corporate, or governmental
An arterial line is a thin catheter inserted into an artery. It is most used in intensive care medicine and anesthesia to monitor blood pressure directly and in real-time and to obtain samples for arterial blood gas analysis. Arterial lines are not used to administer medication, since many injectable drugs may lead to serious tissue damage and require amputation of the limb if administered into an artery rather than a vein. An arterial line is inserted into the radial artery in the wrist, but can be inserted into the brachial artery at the elbow, into the femoral artery in the groin, into the dorsalis pedis artery in the foot, or into the ulnar artery in the wrist. A golden rule is that there has to be collateral circulation to the area affected by the chosen artery, so that peripheral circulation is maintained by another artery if circulation is disturbed in the cannulated artery. Insertion is painful. Arterial lines are inserted by Physicians, Acute Care Nurse Practitioners, ICU Physician Assistants, Anesthesiologist Assistants, Nurse Anesthetists, Respiratory Therapists
Advanced trauma life support
Advanced trauma life support is a training program for medical providers in the management of acute trauma cases, developed by the American College of Surgeons. Similar programs exist for immediate care providers such as paramedics; the program has been adopted worldwide in over 60 countries, sometimes under the name of Early Management of Severe Trauma outside North America. Its goal is to teach a standardized approach to trauma patients. Designed for emergency situations where only one doctor and one nurse are present, ATLS is now accepted as the standard of care for initial assessment and treatment in trauma centers; the premise of the ATLS program is to treat the greatest threat to life first. It advocates that the lack of a definitive diagnosis and a detailed history should not slow the application of indicated treatment for life-threatening injury, with the most time-critical interventions performed early. However, there is no high quality evidence to show that ATLS improves patient outcomes as it has not been studied.
The first and key part of the assessment of patients presenting with trauma is called the primary survey. During this time, life-threatening injuries are identified and resuscitation is begun. A simple mnemonic, ABCDE, is used as a mnemonic for the order; the first stage of the primary survey is to assess the airway. If the patient is able to talk, the airway is to be clear. If the patient is unconscious, he/she may not be able to maintain his/her own airway; the airway can be opened using a chin jaw thrust. Airway adjuncts may be required. If the airway is blocked, the fluid must be cleaned out of the patient's mouth by the help of suctioning instruments. In case of obstruction, pass an endotracheal tube; the chest must be examined by inspection, palpation and auscultation. Subcutaneous emphysema and tracheal deviation must be identified; the aim is to identify and manage six life-threatening thoracic conditions as Airway Obstruction, Tension Pneumothorax, Massive Haemothorax, Open Pneumothorax, Flail chest segment with Pulmonary Contusion and Cardiac Tamponade.
Flail chest, tracheal deviation, penetrating injuries and bruising can be recognized by inspection. Subcutaneous emphysema can be recognized by palpation. Tension Pneumothorax and Haemothorax can be recognized by auscultation. Hemorrhage is the predominant cause of preventable post-injury deaths. Hypovolemic shock is caused by significant blood loss. Two large-bore intravenous lines are established and crystalloid solution may be given. If the person does not respond to this, type-specific blood, or O-negative if this is not available, should be given. External bleeding is controlled by direct pressure. Occult blood loss may be into the chest, pelvis or from the long bones; as of 2012, use of rFVIIa is not supported by evidence. While it may help control bleeding, there is a risk of arterial thrombosis, other than in those with factor VII deficiency, its use should be limited to clinical trials. During the primary survey a basic neurological assessment is made, known by the mnemonic AVPU. A more detailed and rapid neurological evaluation is performed at the end of the primary survey.
This establishes the patient's level of consciousness, pupil size and reaction, lateralizing signs, spinal cord injury level. The Glasgow Coma Scale is a quick method to determine the level of consciousness, is predictive of patient outcome. If not done in the primary survey, it should be performed as part of the more detailed neurologic examination in the secondary survey. An altered level of consciousness indicates the need for immediate reevaluation of the patient's oxygenation and perfusion status. Hypoglycemia and drugs, including alcohol, may influence the level of consciousness. If these are excluded, changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise; the patient should be undressed by cutting off the garments. It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department. Intravenous fluids should be warmed and a warm environment maintained. Patient privacy should be maintained.
When the primary survey is completed, resuscitation efforts are well established, the vital signs are normalizing, the secondary survey can begin. The secondary survey is a head-to-toe evaluation of the trauma patient, including a complete history and physical examination, including the reassessment of all vital signs; each region of the body must be examined. X-rays indicated by examination are obtained. If at any time during the secondary survey the patient deteriorates, another primary survey is carried out as a potential life threat may be present; the person should be removed from the hard spine board and placed on a firm mattress as soon as reasonably feasible as the spine board can cause skin breakdown and pain while a firm mattress provides equivalent stability for potential spinal fractures. A careful and complete examination followed by serial assessments help recognize missed injuries and related problems, allowing a definitive care management; the rate of delayed diagnosis may be as high as 10%.
Mannequin surgical simulators are used in the United States as alternatives to the use of live animals in ATLS courses. In 2014, PETA announced that it was donating surgical simulators to ATLS training centers in 9 countries that agreed to switch from animal use to training on the simulators. Additionally, Anaesthesia Trauma and Critical Care is an international trauma course based in th
Lips are a visible body part at the mouth of humans and many animals. Lips are soft and serve as the opening for food intake and in the articulation of sound and speech. Human lips are a tactile sensory organ, can be an erogenous zone when used in kissing and other acts of intimacy; the upper and lower lips are referred to as the "Labium superius oris" and "Labium inferius oris", respectively. The juncture where the lips meet the surrounding skin of the mouth area is the vermilion border, the reddish area within the borders is called the vermilion zone; the vermilion border of the upper lip is known as the cupid's bow. The fleshy protuberance located in the center of the upper lip is a tubercle known by various terms including the procheilon, the "tuberculum labii superioris", the "labial tubercle"; the vertical groove extending from the procheilon to the nasal septum is called the philtrum. The skin of the lip, with three to five cellular layers, is thin compared to typical face skin, which has up to 16 layers.
With light skin color, the lip skin contains fewer melanocytes. Because of this, the blood vessels appear through the skin of the lips, which leads to their notable red coloring. With darker skin color this effect is less prominent, as in this case the skin of the lips contains more melanin and thus is visually darker; the skin of the lip forms the border between the exterior skin of the face, the interior mucous membrane of the inside of the mouth. The lip skin does not have sweat glands. Therefore, it does not have the usual protection layer of sweat and body oils which keep the skin smooth, inhibit pathogens, regulate warmth. For these reasons, the lips become chapped more easily; the lower lip is formed from a branch of the first pharyngeal arch. The lower lip covers the anterior body of the mandible, it is lowered by the depressor labii inferioris muscle and the orbicularis oris borders it inferiorly. The upper lip covers the anterior surface of the body of the maxilla, its upper half is of usual skin color and has a depression at its center, directly under the nasal septum, called the philtrum, Latin for lower nose, while its lower half is a markedly different, red-colored skin tone more similar to the color of the inside of the mouth, the term vermillion refers to the colored portion of either the upper or lower lip.
It is raised by the levator labii superioris and is connected to the lower lip by the thin lining of the lip itself. Thinning of the vermilion of the upper lip and flattening of the philtrum are two of the facial characteristics of fetal alcohol syndrome, a lifelong disability caused by the mother's consumption of alcohol during pregnancy; the skin of the lips is stratified squamous epithelium. The mucous membrane is represented by a large area in the sensory cortex, is therefore sensitive; the Frenulum Labii Inferioris is the frenulum of the lower lip. The Frenulum Labii Superioris is the frenulum of the upper lip. Trigeminal nerve The infraorbital nerve is a branch of the maxillary branch, it supplies not only the upper lip, but much of the skin of the face between the upper lip and the lower eyelid, except for the bridge of the nose. The mental nerve is a branch of the mandibular branch, it supplies the skin and mucous membrane of labial gingiva anteriorly. The facial artery is one of the six non-terminal branches of the external carotid artery.
This artery supplies both lips by its inferior labial branches. Each of the two branches bifurcate and anastomose with their companion branch from the other terminal; the muscles acting on the lips are considered part of the muscles of facial expression. All muscles of facial expression are derived from the mesoderm of the second pharyngeal arch, are therefore supplied by the nerve of the second pharyngeal arch, the facial nerve; the muscles of facial expression are all specialized members of the panniculus carnosus, which attach to the dermis and so wrinkle, or dimple the overlying skin. Functionally, the muscles of facial expression are arranged in groups around the orbits and mouth; the muscles acting on the lips: Buccinator Orbicularis oris Anchor point for several muscles Modiolus Lip elevation Levator labii superioris levator labii superioris alaeque nasi Levator anguli oris Zygomaticus minor Zygomaticus major Lip depression Risorius Depressor anguli oris Depressor labii inferioris Mentalis Because they have their own muscles and bordering muscles, the lips are movable.
Lips are used for eating functions, like holding food. In addition, lips serve to close the mouth airtight shut, to hold food and drink inside, to keep out unwanted objects. Through making a narrow funnel with the lips, the suction of the mouth is increased; this suction is essential for babies to breast feed. Lips can be used to suck in other contexts, such as sucking on a straw to drink liquids; the lips serve for creating different sounds—mainly labial and labiodental consonant sounds as well as vowel rounding—and thus are an important part of the speech apparatus. The lips enable whistling and the performing of wind instruments such as the trumpet, clarinet and saxophone. People who have hearing loss may unconsciously or consciously lip read to understand speech without needing to perceive the actual sounds; the lip reacts as part of the tactile senses. Lips are sensitive to touch and cold, it is therefore
Blood plasma is a yellowish liquid component of blood that holds the blood cells in whole blood in suspension. In other words, it is the liquid part of the blood that carries cells and proteins throughout the body, it makes up about 55% of the body's total blood volume. It is the intravascular fluid part of extracellular fluid, it is water, contains dissolved proteins, clotting factors, hormones, carbon dioxide and oxygen. It plays a vital role in an intravascular osmotic effect that keeps electrolyte concentration balanced and protects the body from infection and other blood disorders. Blood plasma is separated from the blood by spinning a tube of fresh blood containing an anticoagulant in a centrifuge until the blood cells fall to the bottom of the tube; the blood plasma is poured or drawn off. Blood plasma has a density of 1025 kg/m3, or 1.025 g/ml. Blood serum is blood plasma without clotting factors. Plasmapheresis is a medical therapy that involves blood plasma extraction and reintegration.
Fresh frozen plasma is on the WHO Model List of Essential Medicines, the most important medications needed in a basic health system. It is of critical importance in the treatment of many types of trauma which result in blood loss, is therefore kept stocked universally in all medical facilities capable of treating trauma or that pose a risk of patient blood loss such as surgical suite facilities. Blood plasma volume may be expanded by or drained to extravascular fluid when there are changes in Starling forces across capillary walls. For example, when blood pressure drops in circulatory shock, Starling forces drive fluid into the interstitium, causing third spacing. Standing still for a prolonged period will cause an increase in transcapillary hydrostatic pressure; as a result 12% of blood plasma volume will cross into the extravascular compartment. This causes an increase in hematocrit, serum total protein, blood viscosity and, as a result of increased concentration of coagulation factors, it causes orthostatic hypercoagulability.
Plasma was well-known when described by William Harvey in de Mortu Cordis in 1628, but knowledge of it extends as far back as Vesalius.. The discovery of fibrinogen by William Henson in ca 1770 made it easier to study plasma, as ordinarily, upon coming in contact with a foreign surface – something other than vascular endothelium – clotting factors become activated and clotting proceeds trapping RBCs etc in the plasma and preventing separation of plasma from the blood. Adding citrate and other anticoagulants is a recent advance. Note that, upon formation of a clot, the remaining clear fluid is Serum, plasma without the clotting factors; the use of blood plasma as a substitute for whole blood and for transfusion purposes was proposed in March 1918, in the correspondence columns of the British Medical Journal, by Gordon R. Ward. "Dried plasmas" in powder or strips of material format were developed and first used in World War II. Prior to the United States' involvement in the war, liquid plasma and whole blood were used.
The "Blood for Britain" program during the early 1940s was quite successful based on Charles Drew's contribution. A large project began in August 1940 to collect blood in New York City hospitals for the export of plasma to Britain. Drew was appointed medical supervisor of the "Plasma for Britain" project, his notable contribution at this time was to transform the test tube methods of many blood researchers into the first successful mass production techniques. The decision was made to develop a dried plasma package for the armed forces as it would reduce breakage and make the transportation and storage much simpler; the resulting dried. One bottle contained enough distilled water to reconstitute the dried plasma contained within the other bottle. In about three minutes, the plasma could stay fresh for around four hours; the Blood for Britain program operated for five months, with total collections of 15,000 people donating blood, with over 5,500 vials of blood plasma. Following the "Plasma for Britain" invention, Drew was named director of the Red Cross blood bank and assistant director of the National Research Council, in charge of blood collection for the United States Army and Navy.
Drew argued against the armed forces directive that blood/plasma was to be separated by the race of the donor. Drew insisted that there was no racial difference in human blood and that the policy would lead to needless deaths as soldiers and sailors were required to wait for "same race" blood. By the end of the war the American Red Cross had provided enough blood for over six million plasma packages. Most of the surplus plasma was returned to the United States for civilian use. Serum albumin replaced dried plasma for combat use during the Korean War. Plasma as a blood product prepared from blood donations is used in blood transfusions as fresh frozen plasma or plasma Frozen Within 24 Hours After Phlebotomy; when donating whole blood or packed red blood cell transfusions, O- is the most desirable and is considered a "universal donor," since it has neither A nor B antigens and can be safely transfused to most recipients. Type AB+ is the "universal recipient" type for PRBC donations. However, for plasma the situation is somewhat reverse
Internal bleeding is a loss of blood from a blood vessel that collects inside the body. Internal bleeding is not visible from the outside, it is a serious medical emergency but the extent of severity depends on bleeding rate and location of the bleeding. Severe internal bleeding into the chest, retroperitoneal space and thighs can cause hemorrhagic shock or death if proper medical treatment is not received quickly. Internal bleeding is a medical emergency and should be treated by medical professionals; the most common cause of death in trauma is bleeding. Death from trauma accounts for 1.5 million of the 1.9 million deaths per year due to bleeding. There are two types of trauma: penetrating trauma and blunt trauma. Penetrating trauma can result in internal bleeding, it can occur after a ballistic stab wound. If penetrating trauma occurs in blood vessels close to the heart, it can lead to hemorrhagic or hypovolemic shock and death. Blunt trauma is another cause of vascular injury, it can occur after a high speed deceleration in an automobile accident.
A number of pathological conditions and diseases can lead to internal bleeding. These include: Blood vessel rupture as a result of high blood pressure, esophageal varices, peptic ulcers, or ectopic pregnancy. Other diseases linked to internal bleeding include cancer, hematologic disease, Vitamin K deficiency, rare viral hemorrhagic fevers, such as the Ebola, Dengue or Marburg viruses. Internal bleeding could be caused by medical error as a result of complications after surgical operations or medical treatment; some medication effects may lead to internal bleeding, such as the use of anticoagulant drugs or antiplatelet drugs in the treatment of coronary artery disease. At first, there may be no symptoms of internal bleeding. If an organ is damaged and it bleeds, it can be painful. Over time, internal bleeding can cause low blood pressure, increased heart rate, increased breathing rate, confusion and loss of consciousness. A patient may lose more than 30% of their blood volume before there are changes in their vital signs or level of consciousness.
This is called hemorrhagic or hypovolemic shock, a type of shock that occurs when there is not enough blood to reach organs in the body. Early symptoms include anxiety, increased breathing rate, weak peripheral pulses, cold skin on the arms and legs. If internal bleeding is not treated, the heart and breathing rate will continue to increase while blood pressure and mental status decrease. Internal bleeding can result in death by blood loss; the median time from the onset of hemorrhagic shock to death by exsanguination is 2 hours. Internal bleeding can occur anywhere in the body; some symptoms of internal bleeding depend on the location of the bleed. Some examples of types of internal bleeding include: Head: Intracranial hemorrhage, cerebral hemorrhage, subarachnoid hemorrhage, subdural hematoma, epidural hematoma Torso: cardiac tamponade, pulmonary hemorrhage, aortic aneurysm, gastrointestinal bleeding, blunt kidney trauma, splenic injury retroperitoneal bleeding, postpartum bleeding, ectopic pregnancy Extremities: bone fracture, hemarthrosis Blood loss can be estimated based on heart rate, blood pressure, respiratory rate, mental status.
Advanced trauma life support by the American College of Surgeons separates hemorrhagic shock into four categories. Assessing circulation occurs after breathing. If internal bleeding is suspected, a patient’s circulatory system is assessed through palpation of pulses and doppler ultrasonography, it is important to examine the patient for visible signs that may suggest internal bleeding: a wound bruising blood collection abnormal skin sensation signs of compartment syndromeIt is important to look for the source of the internal bleeding. If internal bleeding is suspected after trauma, a FAST exam may be performed to look for bleeding in the abdomen. If the patient has stable vital signs, they may undergo diagnostic imaging such as a CT scan. If the patient has unstable vital signs, they may not undergo diagnostic imaging and instead may receive immediate medical or surgical treatment. Management of internal bleeding depends on the severity of the bleed. Internal bleeding is a medical emergency and should be treated by medical professionals.
If a patient has low blood pressure, intravenous fluids can be used until they can receive a blood transfusion. In order to replace blood loss and with large amounts of IV fluids or blood, patients may need a central venous catheter. Patients with severe bleeding need to receive large quantities of replacement blood via a blood transfusion; as soon as the clinician recognizes that the patient may have a severe, continuing hemorrhage requiring more than 4 units in 1 hour or 10 units in 6 hours, they should initiate a massive transfusion protocol. The massive transfusion protocol replaces red blood cells and platelets in varying ratios based on the cause of the bleeding, it is important to stop bleeding after identifying the cause of internal bleeding. Studies have shown that taking longer to achieve hemostasis in patients with traumatic causes and non-traumatic causes is associated with an increased death rate.. Un
OCLC Online Computer Library Center, Incorporated d/b/a OCLC is an American nonprofit cooperative organization "dedicated to the public purposes of furthering access to the world's information and reducing information costs". It was founded in 1967 as the Ohio College Library Center. OCLC and its member libraries cooperatively produce and maintain WorldCat, the largest online public access catalog in the world. OCLC is funded by the fees that libraries have to pay for its services. OCLC maintains the Dewey Decimal Classification system. OCLC began in 1967, as the Ohio College Library Center, through a collaboration of university presidents, vice presidents, library directors who wanted to create a cooperative computerized network for libraries in the state of Ohio; the group first met on July 5, 1967 on the campus of the Ohio State University to sign the articles of incorporation for the nonprofit organization, hired Frederick G. Kilgour, a former Yale University medical school librarian, to design the shared cataloging system.
Kilgour wished to merge the latest information storage and retrieval system of the time, the computer, with the oldest, the library. The plan was to merge the catalogs of Ohio libraries electronically through a computer network and database to streamline operations, control costs, increase efficiency in library management, bringing libraries together to cooperatively keep track of the world's information in order to best serve researchers and scholars; the first library to do online cataloging through OCLC was the Alden Library at Ohio University on August 26, 1971. This was the first online cataloging by any library worldwide. Membership in OCLC is based on use of services and contribution of data. Between 1967 and 1977, OCLC membership was limited to institutions in Ohio, but in 1978, a new governance structure was established that allowed institutions from other states to join. In 2002, the governance structure was again modified to accommodate participation from outside the United States.
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