Emergency medicine and general practice

Gunther Abela MD, MFAEM Mosta Health Centre, Primary Health Care Department A+E Department, St Luke’s Hospital, Gwardamangia, Malta Email: gunson@maltanet.net Introduction Emergency Medicine and Immediate Medical Care are relatively new specialties. In Malta, there is quite a considerable area of overlap between these specialties and general practice. Indeed, the family physician is confronted with some sort of medical emergency quite regularly. The brief of this article is to go through recent developments in Emergency Medicine as applied to General Practice. The areas considered are Basic Life Support, Head Injury, Asthma, Anaphylaxis, Community Acquired Pneumonia, Burns and Controlled Hypotensive Resuscitation. Whenever possible, distinct practical guidelines will be suggested as an aid in the clinical management of emergency situations which the family physician may encounter. This overview of new developments is by no means comprehensive but serves to highlight the increasing importance given to the role of the first-line medical practitioner in the emergency situation. Basic Life Support and Automated External Defibrillators The latest guidelines in Basic Life Support (BLS) of the European Resuscitation Council 1,2 (ERC) are illustrated in Figure 1. The algorithm is mostly self-explanatory. However the following points need to be considered in further detail: 1. In adult basic life support, if the rescuer is alone (without a defibrillator), a heart problem should be assumed as the cause of the cardiac arrest. The rescuer should thus go for help as soon as it has been established that the victim is not breathing. The rationale behind this guideline is that cardiac arrests due to a heart problem usually result from ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT). The most effective treatment for this type of cardiac arrest is defibrillation: one has to get a defibrillator to the patient as early on as possible. On the other hand, if the likely cause of unconsciousness is a breathing problem, then the rescuer should perform cardiopulmonary resuscitation (CPR) for about 1 minute before seeking help. Instances in which a breathing problem is assumed include trauma, drowning, drug or alcohol intoxication or if the patient is younger than 8 years of age. The only exception to this rule is if the patient is an infant or child with known heart disease and the collapse was sudden and not caused by trauma or poisoning. 2. The ratio of rescue breaths to chest compressions is always the same independent of whether there are one or two rescuers. 3. The landmarks for chest compressions are as follows: • Adult: middle of the lower half of the sternum (i.e. roughly two fingers’ breadth from the point where the ribs join the sternum). • Child: same position as in adults, roughly one finger’s breadth from the point where the ribs join the sternum. • Infant: one finger’s breadth below an imaginary line joining the infant’s nipples – one has to use the tips of two fingers instead of the bimanual approach.