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1、Department of Emergency Medicine, SAHZU,Medical Emergencies,Mao Zhang, MD,1. Airway emergencies 2. Heat-induced injury 3. Overdoses,Overviews,1. Airway emergencies, Acute upper airway obstruction Pneumothorax Near-drowning,Acute upper airway obstruction,1. General principals 1.1Etiology . In awake p
2、atients - a foreign body, angioedema . In unconscious patients tongue, foreign body, trauma, infection, angioedema,2. Diagnosis 2.1 Clinical presentation 2.1.1 History commonly unavailable 2.1.2 Physical examination Conscious patient: stridor,impaired phonation,sternal or suprasternal retraction,cho
3、king sign, repiratory distress Unconscious patient: labored breathing, apnea,difficult ventilation - All patient look for urticaria, angioedema, fever, and evidence of trauma - partial obstruction in the awake patient with adequate ventilation: looking for airway swelling, trismus, pharyngeal obstru
4、ction, respiratory retractions, stridor,neck mass - airway obstruction in an unconscious patient without intact ventilation: examine the upper airway visually for evidence of obstruction.,2.2 Differential diagnosis -trauma to the face and neck, foreign body, infection, tumor, angioedema, laryngospas
5、m . 2.3 Diagnostic testing 2.3.1 Imaging: partial obstruction in the awake patient with adequate ventilation: - Radiography of the neck (PA,L view): perofrmed in ER - rapid CT:,2.4 Diagnostic procedures partial obstruction in the awake patient with adequate ventilation: - indirect laryngoscopy - fib
6、eroptic nasopharyngolaryngoscopy,3. Treatment: prevent CA 3.1 Nonsurgical management 3.1.1 Awake patient without ventilation: - Heimlich maneuver - a second technique (back slaps, chest thrusts) 3.1.2 Unconscious patient without ventilation: - head tilt-chin lift maneuver or a jaw thrust - oral or n
7、asal airway - ventilate BVM - laryngoscope to remove FB - the supine Heimlich maneuver or chest thrust,3.2 Surgical management . Airway obstruction in an unconscious patient without intact ventilation: - direct laryngoscopy and endotracheal intubation - a surgical airway - cricothyrotomy using 12-14
8、G catheter with high-flow O2,1. Airway emergencies,Acute upper airway obstruction Pneumothorax Near-drowning,Pneumothorax,1. General principals - primary spontaneous pneumothorax - secondary spontaneous pneumothorax - traumatic pneumothorax - latrogenic pneumothorax - Tension pneumothorax: hypotensi
9、on, respiratory distress,2. Diagnosis 2.1 Clinical presentation 2.1.1 History acute onset of ipsilateral chest or shoulder pain a history of recent chest trauma or medical procedure dyspnea,2.1.2 Physical examination decreased breath sounds, decreased vocal fremitus, a more resonant percussion note
10、- tachypnea, respiratory distress, larger and relatively immobile hemithorax severe distress, diaphoresis, cyanosis, and hypotension subcutaneous emphysema,2.2 Diagnostic testing 2.2.1 ECG - diminished anterior QRS amplitude and an anterior axis shift, electromechanical dissociation 2.2.2 Imaging ch
11、est radiograph : - a separation of the pleural shadow from the chest wall - caution for mechanically ventilated patients - mediastinal and tracheal shift, depression of ipsilateral diaphragm,3. Treatment - depends on cause, size, and degree of physiologic derangement 3.1 Primary pneumothorax - resol
12、ve without intervention (10 dys for 15%) - discharge, - administer high-flow oxygen (small, mildly symptomatic) - insert a thoracostomy tube (larger than 15%20%, symptomatic) - pleural sclerosis,3.2 Secondary pneumothorax - symptomatic and require lung reexpasion - thoracostomy tube and suction requ
13、ired - consult a pulmonologist - surgery for persistent air leak,3.3 Iatrogenic pneumothorax - managed conservatively, admit the patient, administer oxygen, and repeat the chest radiograph in 6 hours - a pneumothorax catheter with aspiration or a one-way valve - managed with a chest tube and suction
14、,3.4 Tension pneumothorax - decompress the affected hemithorax immediately with a 14-gauge needle attached to a fluid-filled syringe - seal any chest wound with an occlusive dressing - arrange for placement of a thoracostomy tube,1. Airway emergencies,Acute upper airway obstruction Pneumothorax Near
15、-drowning,Near-drowning,1. General principals 1.1Definition - defined as the survival for at least 24 hours after submersion in a liquid medium - risk factors: youth, inability to swim, alcohol and drug use, barotrauma, head and neck trauma, epilepsy, syncope - freshwater drowning and saltwater drow
16、ning: - differences: pathophysiology - common: hypoxemia and tissue hypoxia (related to V/Q mismatch, acidosis, and hypoxic brain injury with cerebral edema), hypothermia, pneumonia,2. Diagnosis 2.1 Clinical presentation 2.1.1 Laboratories - serum electrolytes, CBC, ABGs - obtain blood alcohol level and drug screen if the mental status is not normal 2.1.2 ECG - monitor the cardiac rhythm continuously,3. Treatment 3.1 Resuscitation - airway management and ventilatio
