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EMERGENCY MEDICINE – AN INTERNATIONAL PERSPECTIVE Edited by Michael Blaivas Emergency Medicine – An International Perspective Edited by Michael Blaivas Published by InTech Janeza Trdine 9, 51000 Rijeka, Croatia Copyright © 2012 InTech All chapters are Open Access distributed under the Creative Commons Attribution 3.0 license, which allows users to download, copy and build upon published articles even for commercial purposes, as long as the author and publisher are properly credited, which ensures maximum dissemination and a wider impact of our publications. After this work has been published by InTech, authors have the right to republish it, in whole or part, in any publication of which they are the author, and to make other personal use of the work. Any republication, referencing or personal use of the work must explicitly identify the original source. As for readers, this license allows users to download, copy and build upon published chapters even for commercial purposes, as long as the author and publisher are properly credited, which ensures maximum dissemination and a wider impact of our publications. Notice Statements and opinions expressed in the chapters are these of the individual contributors and not necessarily those of the editors or publisher. No responsibility is accepted for the accuracy of information contained in the published chapters. The publisher assumes no responsibility for any damage or injury to persons or property arising out of the use of any materials, instructions, methods or ideas contained in the book. Publishing Process Manager Ivona Lovric Technical Editor Teodora Smiljanic Cover Designer InTech Design Team First published March, 2012 Printed in Croatia A free online edition of this book is available at www.intechopen.com Additional hard copies can be obtained from orders@intechweb.org Emergency Medicine – An International Perspective, Edited by Michael Blaivas p. cm. ISBN 978-953-51-0333-2 Contents Preface IX Chapter 1 Intensive Care Management of the Traumatic Brain Injury 3 Akarsu Ayazoglu Tülin and Özden Nihan Chapter 2 Lumbar Puncture: Techniques, Complications and CSF Analyses 17 Ali Moghtaderi, Roya Alavi-Naini and Saleheh Sanatinia Chapter 3 Delays in the Diagnosis of Pulmonary Thromboembolism and Risk Factors 63 Savas Ozsu Chapter 4 Emergency Medicine in China 73 Xiang-Yu Hou Chapter 5 Emergent Procedure Training in the 21st Century 95 Ernest E. Wang Chapter 6 Emergency Medicine in the Czech Republic 109 Jiri Pokorny Chapter 7 Medical Instructions of the XVIII Century to Resuscitate the Apparently Dead: Rescuing the Drowned to Define the Origins of the Emergency Medicine 121 Silvia Marinozzi, Giuliano Bertazzoni and Valentina Gazzaniga Chapter 8 Considerations in Mass Casualty and Disaster Management 143 Peter Aitken and Peter Leggat Chapter 9 Prehospital Airway Management 183 Flavia Petrini, Maurizio Menarini and Elena Bigi VI Contents Chapter 10 Procedural Sedation and Analgesia in Emergency Department 199 Balwinder Singh, Akhilesh Kumar Tiwari, Sanjay Kumar Verma, Pedro Whatts, Dipti Agarwal and Subhash Chandra Chapter 11 Traumatic Brain Injury 209 Zahra Gardezi Preface Emergency medicine is, by its nature, borne out of necessity and through painful lessons that specialized care is required for many patients presenting to hospital “ERs” with complaints ranging from minor ailments to life threatening illness and even in peri-arrest states. While individual medical specialists can often provide care for a specific disease process, none are able to one minute treat a poly-trauma patient by intubating them and placing a chest tube and then move on to treating a patient with myocardial infarction, diagnose an ectopic pregnancy or resuscitate a septic shock patient. It is this diversity that makes emergency medicine exiting for its practitioners and also creates challenges for the field as it develops in the midst of established older specialties all of whom have to interact with emergency patients as well. In fact, it is exactly this fact that weighs on many students who are in the process of making decisions about their future in the final year of medical school. Like many students, I was interested in multiple different fields. Surgery was exciting and active, internal medicine and its sub-specialties required rigorous thought and analysis, anesthesiology allowed control of patients' pain and vital functions, while radiology held the capability to look within the body without penetrating it. The common theme that attracts many to emergency practice is an interested in all of the most exciting aspects of each major specialty but a reluctance to giving up on what other specialties offered at the same time. Emergency medicine, unlike any other field, combines all of these aspects for its practitioners. However, while offering a combination of skills and knowledge found nowhere else, it offers unusual challenges at the same time. There are few opportunities to develop long term relationships with patients and the need to be ready to meet any challenge from psychiatric to surgical or medical disasters can be stressful while at the same time stimulating. Thus a broad core knowledge of anatomy, pathophysiology, pharmacology and a variety of non- invasive and invasive procedures is critical. Having watched emergency medicine develop in the United States over the last twenty years I realize how much I have seen of the foundation a major new specialty and what a critical role it plays. In addition, over the last decade I have had the privilege of being involved with a multitude international colleagues. This has been one of the most eye opening and professionally inspiring experiences I have had. The diverse nature of emergency practice and growth around the world highlights the X Preface basic principle of emergency medicine, any time, anything and for many this also includes anywhere. Multiple specialists practice emergency medicine around the globe and in some cases are asked to provide care that would challenge and inspire colleagues in North America, the birthplace of emergency medicine. This book is unique among its peers as it offers a broad international perspective and discusses practice approaches from around the globe. In addition, key elements of emergency medicine practice are covered for the reader discussing historical and cutting edge approaches and their scientific basis. The chapters that make up this textbook should be of interest to any reader who treats or is interested in the treatment of the emergency patient whether the patient is located in the pre-hospital, emergency department or in-hospital settings. Dr. Michael Blaivas Department of Emergency Medicine, Northside Hospital Forsyth Atlanta, Georgia [...]... simple commands 1=No verbalization of any type 2=Moans/groans, no speech 3=Intelligible, no sustained sentences 4=Converses but confused, disoriented 5=Converses and oriented 4 Emergency Medicine – An International Perspective Intracranial physiology and mechanical ventilation The goals of positive-pressure ventilation (PPV) in patients with multitrauma with head trauma are improving oxygenation and controlling... aroused from alarms must be arranged Calling the family members, the relexing exercises, musical therapy, masaj and sitting exercises are important in control of anxiety and ajitation of patients Safe and effective management of the pain and anxiety needs a delicate balance for analgesia and sedation protocols while managing delirium status The weaning of patients from mechanical ventilation is often... adrenocorticotrophic hormone (ACTH), cortisol, antidiuretic hormone (ADH), growth hormone (GH) and glucagon The stress response reduces insulin uptake, causing hyperglycaemia, relative glucose intolerance and insulin resistance, and promotes 24 Emergency Medicine – An International Perspective catabolism of proteins and lipids and a decrease in gastrointestinal motility and urine output Benzodiazepines The benzodiazepines... intracranial pressure; MAP, mean arterial pressure Table 5 Cerebral and systemic characteristics of the available molecules 14 Emergency Medicine – An International Perspective Barbiturate, benzodiazepins, propofol and narcotics are all used as a sedative agent Propofol is very lipid soluble, has a large volume of distribution, and can be given for prolonged periods of time without significant changes... balance and electrolyte replacement Prior to trial of weaning, there should be no residual neuromuscular blockade and sedation should be stoped or decreased in appropirate level so that the patient must be awake, cooperative and in a semirecumbent position Weaning is likely to fail if the patient is confused, agitated or unable to cough 8 Emergency Medicine – An International Perspective Modes of weaning... central nervous system, and cirulatory system, it should also consist monitoring of metabolism especially glucose metabolism, temperature and electrolite balance in short intervals With these invasive and noninvasive monitoring, all the precausions for the problems should be ready 2 Emergency Medicine – An International Perspective Beside heavy brain injury may result in a permanant neurologic sequale,... pressure and can cause direct compression of vital cerebral structures and lead to herniation Appropriate management of intracranial hypertension begins with stabilization of the patient and simultaneous assessment of the level of sensorium and the cause of it Stabilization is initiated with securing the airway, ventilation and circulation(87) The management of the patient involves the maintenance of an. .. ischemia 10      Emergency Medicine – An International Perspective Amnesia during paralysis with muscle relaxants During interventions (line insertion, tracheostomy) To prevent movement (during imaging and transfering of the patient) Facilitate sleep Facilitate nursing management Properties of an ideal agent for neurointensive care sedation:                  Rapid onset and rapid recovery... herniation, and, ultimately, brain death occur ICP monitoring allows for early detection of intracranial hypertension and subsequent aggressive management ICP monitoring helps the earlier detection of intracranial mass lesions and can limit the indiscriminate use of therapies to control ICP which themselves can be potentially harmful It can also reduce ICP by CSF drainage and thus improve cerebral perfusion and... 1 Intensive Care Management of the Traumatic Brain Injury Akarsu Ayazoglu Tülin1 and Özden Nihan2 1Chief Asistant Kartal Kosuyolu Highly Specialized Education and Training Hospital İstanbul 2Göztepe Education and Training Hospital Istanbul Turkey 1 Introduction Traumatic brain injury has been major cause of mortality and morbidity worldwide, especially in children and young adults and it has been continuing . EMERGENCY MEDICINE – AN INTERNATIONAL PERSPECTIVE Edited by Michael Blaivas Emergency Medicine – An International Perspective Edited by Michael. disoriented Oriented 5=Converses and oriented Table 1. Glascow Coma Scale. Emergency Medicine – An International Perspective 4 Intracranial physiology and mechanical ventilation The goals. cooperative and in a semirecumbent position. Weaning is likely to fail if the patient is confused, agitated or unable to cough. Emergency Medicine – An International Perspective 8 Modes of weaning