1.
Emergency medicine
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Different models for emergency medicine exist internationally. In developing countries, emergency medicine is still evolving and international emergency medicine programs offer hope of improving basic emergency care where resources are limited and 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 care of internal medical and surgical conditions. Emergency physicians also provide primary care to patients during off hours. Emergency medicine is distinct from urgent care, which refers to immediate healthcare for less emergent medical issues, however, many emergency physicians work in urgent care settings, since there is obvious overlap. Emergency medicine also includes aspects of acute primary care, and shares with family medicine the uniqueness of seeing all patients regardless of age. The emergency physician workforce also includes many competent physicians who trained in other specialties, the practice of emergency medicine is often quite different in rural areas where there are far fewer consultants and health care resources. In these areas, family physicians with additional skills in emergency medicine often staff emergency departments, rural emergency physicians may be the only health care providers in the community, and require skills that include primary care and obstetrics. Patterns vary by country and region, in the United States, the employment arrangement of emergency physician practices are either private, institutional, corporate, or governmental. In the United Kingdom, all consultants in emergency medicine work in the National Health Service, rural emergency departments may be headed by general practitioners alone, sometimes with non-specialist qualifications in emergency medicine. Dominique Jean Larrey is sometimes called the father of medicine for his strategies during the French wars. Emergency medicine as an independent medical specialty is relatively young, in many smaller emergency departments, nurses would triage patients and physicians would be called in based on the type of injury or illness. Family physicians were often on call for the department. Many of the pioneers of medicine were family physicians and other specialists who saw a need for additional training in emergency care. During this period, groups of physicians began to emerge who had left their respective practices in order to devote their work completely to the ED, in the UK in 1952, Maurice Ellis was appointed as the first casualty consultant at Leeds General Infirmary. In 1967, the Casualty Surgeons Association was established with Maurice Ellis as its first President, many hospitals and care centers feature departments of emergency medicine, where patients can receive acute care without an appointment. While many patients are treated for life-threatening injuries, others utilize the emergency department for non-urgent reasons such as headaches or a cold. As such, EDs can adjust staffing ratios and designate an area of the department for faster patient turnover to accommodate a variety of patient needs and volumes
2.
Blood plasma
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Blood plasma is a straw coloured liquid component of blood that normally holds the blood cells in whole blood in suspension, this makes plasma the extracellular matrix of blood cells. It makes up about 55% of the total blood volume. It is the fluid part of extracellular fluid. It is mostly water, and contains dissolved proteins, glucose, clotting factors, electrolytes, hormones, carbon dioxide, Plasma also serves as the protein reserve of the human body. It plays a role in an intravascular osmotic effect that keeps electrolytes in balanced form and protects the body from infection. Blood plasma is prepared by spinning a tube of fresh blood containing an anticoagulant in a centrifuge until the blood fall to the bottom of the tube. The blood plasma is then poured or drawn off, Blood plasma has a density of approximately 1025 kg/m3, or 1.025 g/ml. Blood serum is blood plasma without clotting factors, in other words, plasmapheresis is a medical therapy that involves blood plasma extraction, treatment, and reintegration. Fresh frozen plasma is on the WHO Model List of Essential Medicines, 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, standing still for a prolonged period will cause an increase in transcapillary hydrostatic pressure. As a result, approximately 12% of blood plasma volume will cross into the extravascular compartment and 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. The use of 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. Dried plasmas in powder or strips of material format were developed, 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 Drews 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 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. Nonetheless, the decision was made to develop a dried plasma package for the forces as it would reduce breakage and make the transportation, packaging. The resulting dried plasma package came in two tin cans containing 400 cc bottles, one bottle contained enough distilled water to reconstitute the dried plasma contained within the other bottle
3.
Blood donation
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A blood donation occurs when a person voluntarily has blood drawn and used for transfusions and/or made into biopharmaceutical medications by a process called fractionation. Donation may be of whole blood, or of components directly. Blood banks often participate in the process as well as the procedures that follow it. Today in the world, most blood donors are unpaid volunteers who donate blood for a community supply. In poorer countries, established supplies are limited and donors usually give blood when family or friends need a transfusion. Many donors donate as an act of charity, but in countries that allow paid donation some donors are paid, Donors can also have blood drawn for their own future use. Donating is relatively safe, but some donors have bruising where the needle is inserted or may feel faint, potential donors are evaluated for anything that might make their blood unsafe to use. The screening includes testing for diseases that can be transmitted by a transfusion, including HIV. The donor must also answer questions about history and take a short physical examination to make sure the donation is not hazardous to his or her health. How often a donor can donate varies from days to months based on what component they donate, for example, in the United States, donors must wait eight weeks between whole blood donations but only seven days between plateletpheresis donations and twice per seven-day period in plasmapheresis. The amount of blood drawn and the methods vary, the collection can be done manually or with automated equipment that takes only specific components of the blood. Most of the components of used for transfusions have a short shelf life. Blood donations are divided into groups based on who will receive the collected blood, an allogeneic donation is when a donor gives blood for storage at a blood bank for transfusion to an unknown recipient. A directed donation is when a person, often a family member, directed donations are relatively rare when an established supply exists. A replacement donor donation is a hybrid of the two and is common in developing such as Ghana. In this case, a friend or family member of the recipient donates blood to replace the blood used in a transfusion. When a person has blood stored that will be transfused back to the donor at a date, usually after surgery. Blood that is used to make medications can be made from allogeneic donations or from donations exclusively used for manufacturing and this blood is sometimes treated as a blood donation, but may be immediately discarded if it cannot be used for transfusion or further manufacturing
4.
Perfusion
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Perfusion is the passage of fluid through the circulatory system or lymphatic system to an organ or a tissue, usually referring to the delivery of blood to a capillary bed in tissue. The word is derived from the French verb perfuser meaning to pour over or through, all animal tissues require an adequate blood supply for health and life. Poor perfusion, that is, ischemia, causes problems, as seen for example in coronary artery disease, deep vein thrombosis. Tests verifying that adequate perfusion exists are a part of an assessment process that are performed by medical or emergency personnel. The most common methods include evaluating a bodys skin color, temperature, condition, during major surgery, especially cardiothoracic surgery, perfusion must be maintained and managed by the health professionals involved, rather than left to the bodys homeostasis alone. As the lead surgeons are often too busy to handle all hemodynamic control by themselves, there are more than one hundred thousand perfusion procedures annually. In 1920, August Krogh was awarded the Nobel Prize in Physiology or Medicine for his discovering the mechanism of regulation of capillaries in skeletal muscle. Krogh was the first to describe the adaptation of blood perfusion in muscle, underperfusion is also called poor perfusion and malperfusion is any type of incorrect perfusion. Heart tissues, for example, are classified as being overperfused because they normally are receiving more blood than the rest of tissues in the organism. In the case of cells, extra blood flow in them is used for thermoregulation of a body. In equations, the symbol Q̇ often represents perfusion or, relatedly, microspheres that are labeled with radioactive isotopes have been widely used since the 1960s. Radioactively labeled particles are injected into the test subject and a detector measures radioactivity in tissues of interest. Application of this process is used to develop radionuclide angiography, a method of diagnosing heart problems, in the 1990s, methods for using fluorescent microspheres became a common substitute for radioactive particles. Perfusion of various tissues can be measured in vivo with nuclear medicine methods which are mainly positron emission tomography. The first is based on the use of an injected contrast agent that changes the magnetic susceptibility of blood, brain perfusion can be estimated with contrast-enhanced computed tomography. Perfusion can be determined by measuring the thermal diffusion and then separating it into thermal conductivity. RCBF is usually measured continuously in time and it is necessary to stop the measurement periodically to cool down and reassess the thermal conductivity
5.
Lip
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Lips are a visible body part at the mouth of humans and many animals. Lips are soft, movable, and serve as the opening for food intake and in the articulation of sound, human lips are a tactile sensory organ, and 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, the juncture where the lips meet the surrounding skin of the mouth area is the vermilion border, and the typically reddish area within the borders is called the vermilion zone. The vermilion border of the lip is known as the cupids bow. The fleshy protuberance located in the center of the lip is a tubercle known by various terms including the procheilon, the tuberculum labii superioris. The vertical groove extending from the procheilon to the septum is called the philtrum. The skin of the lip, with three to five layers, is very 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 case the skin of the lips contains more melanin. The skin of the lip forms the border between the skin of the face, and the interior mucous membrane of the inside of the mouth. The lip skin is not hairy and 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, and regulate warmth. For these reasons, the lips dry out faster and become chapped more easily, the lower lip is formed from the mandibular prominence, a branch of the first pharyngeal arch. The lower lip covers the 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. It is raised by the levator labii superioris and is connected to the lip by the thin lining of the lip itself. The skin of the lips is stratified squamous epithelium, the mucous membrane is represented by a large area in the sensory cortex, and is therefore highly 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 and 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
6.
Internal bleeding
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Internal bleeding is a loss of blood that occurs from the vascular system into a body cavity or space. It is a medical emergency and the extent of severity depends on bleeding rate. It can cause death and cardiac arrest if proper medical treatment is not received quickly, a number of medical conditions may lead to internal bleeding. Common causes include trauma, various conditions and complications of medical therapy. Common locations include the gastrointestinal tract, the aorta and intracranial hemorrhage, internal bleeding can be caused by blunt trauma such as high speed deceleration in an automobile accident, or by penetrating trauma such as a ballistic or stab wound. A number of conditions and diseases can lead to internal bleeding. These include blood vessel rupture as a result of blood pressure, aneurysms. Another common cause of bleeding is carcinoma, either of the gastro-intestinal tract, of the lung, or more rarely of other organs such as the prostate. Some viruses may cause a type of internal bleeding called viral hemorrhagic fever, such as the Ebola, Dengue or Marburg viruses, internal bleeding could be an iatrogenic artifact 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. If there is pressure, it may lead to death or a brain hemorrhage, cases of internal bleeding are usually termed as hemorrhage, even though the term is general to all kinds of bleeding. A minor case of internal bleeding results in ecchymosis, or a bruise, blood expands under the skin, causing discoloration
7.
Vasoconstriction
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Vasoconstriction is the narrowing of the blood vessels resulting from contraction of the muscular wall of the vessels, in particular the large arteries and small arterioles. The process is the opposite of vasodilation, the widening of blood vessels, the process is particularly important in staunching hemorrhage and acute blood loss. When blood vessels constrict, the flow of blood is restricted or decreased and this makes the skin turn paler because less blood reaches the surface, reducing the radiation of heat. On a larger level, vasoconstriction is one mechanism by which the body regulates, medications causing vasoconstriction, also known as vasoconstrictors, are one type of medicine used to raise blood pressure. Generalized vasoconstriction usually results in an increase in blood pressure. The extent of vasoconstriction may be slight or severe depending on the substance or circumstance, many vasoconstrictors also cause pupil dilation. Medications that cause vasoconstriction include, antihistamines, decongestants, and stimulants, severe vasoconstriction may result in symptoms of intermittent claudication. The mechanism that leads to results from the increased concentration of calcium within vascular smooth muscle cells. However, the mechanisms for generating an increased intracellular concentration of calcium depends on the vasoconstrictor. Smooth muscle cells are capable of generating action potentials, but this mechanism is utilized for contraction in the vasculature. Hormonal or pharmokinetic components are more physiologically relevant, two common stimuli for eliciting smooth muscle contraction are circulating epinephrine and activation of the sympathetic nervous system that directly innervates the muscle. These compounds interact with cell surface adrenergic receptors, the rise in intracellular calcium complexes with calmodulin, which in turn activates myosin light-chain kinase. This enzyme is responsible for phosphorylating the light chain of myosin to stimulate cross-bridge cycling and this reduction in calcium removes the stimulus necessary for contraction, allowing for a return to baseline. Factors that trigger vasoconstriction can be of exogenous or endogenous origin, ambient temperature is an example of the former. Cutaneous vasoconstriction will occur because of the exposure to the severe cold. Examples of endogenous factors include the nervous system, circulating hormones. Examples include amphetamines, antihistamines and cocaine, many are used in medicine to treat hypotension and as topical decongestants. Vasoconstrictors are also used clinically to increase blood pressure or to reduce blood flow
8.
Mottling
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Mottle is a pattern of irregular marks, spots, streaks, blotches or patches of different shades or colours. It is commonly used to describe the surface of plants or the skin of animals, in plants, mottling usually consists of yellowish spots on plants, and is usually a sign of disease or malnutrition. The medical term for mottled skin is dyschromia, although this is not always the case, mottling can occur in the dying patient and commonly indicates that the end of life is near. Mottling usually occurs in the extremities and progresses up as cardiac function declines, in animals, mottling may be a sign of disease, but may also be a hereditary trait, such as seen with the champagne and leopard complex genes in horses. Mottles can also refer to discoloration in processed food, such as butter, in geology, mottled refers to a patchy/blotch texture of alteration or interbedding, commonly found in limestone and commonly caused by bioturbation. Mottling can also refer to a defect which can occur with effect coatings. The total color impression shows irregular areas of lightness variations and these patches are usually visually evaluated, described as a mottling effect. Some also feel that it reminds them of clouds and this effect is especially noticeable on large body panels. It can be caused by the formulation, as well as variations in the application process. For example, disorientation of the flakes or film thickness variations of the basecoat can lead to various mottle sizes resulting in a non-uniform appearance. The visual perception of mottling is dependent on the distance, Large mottles can be seen in far distance evaluation. The visual evaluation of mottling is very subjective, as it depends on the conditions, the observing distance. In graphics printing mottling refers to an uneven coloration resulting from letterpressed printing of textured papers, due to the uneven surface, not all fibers of the paper are evenly saturated with color unlike offset printing. The irregular lightness variations caused by mottling can be measured with specially made instruments. These instruments simulate visual evaluation under different observing angles and characterize clouds / mottles by their size, small to large mottles are measured under three observing angles, in which the scan length can usually be varied from 10 to 100 cm. The measurement results are independent of color and curvature of the surface, the specific measurement process for one such instrument is as follows. It first optically scans the surface and measures the lightness variations, the mottling meter is rolled across the surface for a defined distance of 10 to 100 cm and measures the lightness variations point by point. The measurement signal is divided via mathematical filter functions into 6 different size ranges, the higher the value is, the more visible the mottling effect
9.
Intravenous drip
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Intravenous therapy is the infusion of liquid substances directly into a vein. Intravenous infusions are commonly referred to as drips, the intravenous route is the fastest way to deliver fluids and medications throughout the body. Intravenous therapy may be used for administration, to correct electrolyte imbalances, to deliver medications. IVs can be categorized by type of vein the tube inserted, called the catheter. A peripheral IV is used on peripheral veins and this is the most common type of IV therapy used. Central IV lines have their catheters that are advanced through a vein and empty into a central vein, usually the superior vena cava. Other advantages are that because it empties near the heart, medications can also be distributed to the rest of the body. As there is room for multiple parallel compartments within the catheter, caregivers can also measure central venous pressure and other physiological variables through the line. They are also longer, which as reflected in Poiseuilles law, requires higher pressure to achieve the same flow, central IV lines carry risks of bleeding, infection, gangrene, thromboembolism and gas embolism. Surrounding structures such as the pleura and carotid artery are also at risk of damage with the potential for pneumothorax or even cannulation of the artery. There are several types of central IVs, depending on the route that the catheter takes from the outside of the body to the vein, typical uses for a PICC include, long chemotherapy regimens, extended antibiotic therapy, or total parenteral nutrition. This is usually done by measuring the distance to a landmark, such as the suprasternal notch. An X-ray must be used to verify that the tip is in the place when fluoroscopy was not used during the insertion. A PICC may have a tube and connector, two or three compartments, each with its own external connector. Power-injectable PICCs are now available as well, from the outside, a single-lumen PICC resembles a peripheral IV, except that the tubing is slightly wider. The insertion site requires better protection than that of a peripheral IV, however, a PICC poses less of a systemic infection risk than other central IVs, because the insertion site is usually cooler and dryer than the sites typically used for other central lines. This helps to slow the growth of bacteria which could reach the bloodstream by traveling under the skin along the outside of the catheter, although special training is required, a PICC does not require the skill level of a physician or surgeon. It is also externally unobtrusive, and with proper hygiene and care can be left in place for months to years if needed for patients who require extended treatment, also, as a PICC travels through the axilla, it can become kinked, causing poor function
10.
Coagulation
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Coagulation is the process by which blood changes from a liquid to a gel, forming a blood clot. It potentially results in hemostasis, the cessation of blood loss from a damaged vessel, the mechanism of coagulation involves activation, adhesion, and aggregation of platelets along with deposition and maturation of fibrin. Disorders of coagulation are disease states which can result in bleeding or obstructive clotting, Coagulation is highly conserved throughout biology, in all mammals, coagulation involves both a cellular and a protein component. The system in humans has been the most extensively researched and is the best understood, Coagulation begins almost instantly after an injury to the blood vessel has damaged the endothelium lining the vessel. Platelets immediately form a plug at the site of injury, this is called primary hemostasis and this localization of platelets to the extracellular matrix promotes collagen interaction with platelet glycoprotein VI. Binding of collagen to glycoprotein VI triggers a cascade that results in activation of platelet integrins. Activated integrins mediate tight binding of platelets to the extracellular matrix and this process adheres platelets to the site of injury. Activated platelets will release the contents of stored granules into the blood plasma, the granules include ADP, serotonin, platelet-activating factor, vWF, platelet factor 4, and thromboxane A2, which, in turn, activate additional platelets. The granules contents activate a Gq-linked protein receptor cascade, resulting in increased concentration in the platelets cytosol. The calcium activates protein kinase C, which, in turn, pLA2 then modifies the integrin membrane glycoprotein IIb/IIIa, increasing its affinity to bind fibrinogen. The activated platelets change shape from spherical to stellate, and the fibrinogen cross-links with glycoprotein IIb/IIIa aid in aggregation of adjacent platelets, the coagulation cascade of secondary hemostasis has two initial pathways which lead to fibrin formation. These are the activation pathway, and the tissue factor pathway which both lead to the same fundamental reactions that produce fibrin. Coagulation factors are generally indicated by Roman numerals, with a lowercase a appended to indicate an active form, the coagulation factors are generally serine proteases, which act by cleaving downstream proteins. For example, FVIII and FV are glycoproteins, and Factor XIII is a transglutaminase, the coagulation factors circulate as inactive zymogens. The coagulation cascade is therefore divided into three pathways. The tissue factor and contact activation pathways both activate the final common pathway of factor X, thrombin and fibrin, fVIIa circulates in a higher amount than any other activated coagulation factor. FVII is itself activated by thrombin, FXIa, FXII and FXa, the activation of FX by TF-FVIIa is almost immediately inhibited by tissue factor pathway inhibitor. FXa and its co-factor FVa form the complex, which activates prothrombin to thrombin
11.
Norepinephrine (medication)
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Norepinephrine, also known as noradrenaline, is a medication used to treat people with very low blood pressure. It is the medication used in sepsis if low blood pressure does not improve following intravenous fluids. It is the molecule as the hormone and neurotransmitter norepinephrine. It is given by injection into a vein. Common side effects include headache, slow rate, and anxiety. Other side effects include an irregular heartbeat, if it leaks out of the vein at the site it is being given, norepinephrine can result in limb ischemia. If leakage occurs the use of phentolamine in the area affected may improve outcomes, norepinephrine works by binding and activating alpha adrenergic receptors. Norepinephrine was discovered in 1946 and was approved for use in the United States in 1950. It is avaliable as a generic medication, the wholesale cost in the developing world as of 2015 is about 0.42 USD per vial of four milligrams. In the United Kingdom this amount costs the NHS about 4.40 pounds and it acts on both α1 and α2 adrenergic receptors to cause blood vessel contraction. Its effects are limited to the increasing of blood pressure through agonist activity on α1 and α2 receptors. Norepinephrine is the INN while noradrenaline is the BAN
