MANAGEMENT OF MEDICOLEGAL EMERGENCIES

- AN INTENSIVIST ‘ S PERSPECTIVE

Dr Vaidyanathan.R DA,DNBConsultant anaesthesiologist and intensivist

CAUVERY HOSPITALMYSORE

MEDICOLEGAL CASES• A medico-legal case is a case of injury/

illness where the attending doctor, after history and examination thinks that some investigation by law enforcement agencies is essential to establish and fix responsibility for the case in accordance with the law of the land.

• Simply put, it is a medical case with legal implications or a legal case requiring medical expertise.

EMERGENCIES• Any acute medical, surgical or obstetric

condition which deteriorates rapidly often leading to death .

• Timely and immediate intervention by trained personnel saves lives.

• Often involves Intensivist or emergency medicine consultants early in management

• Multidisciplinary approach

THE EMERGENCIES

• Polytrauma• Poisoning• Drug overdosages• Burns• Assaults• Gun shot injuries• Drowning • Hanging• Snake /animal bite

TYPICAL ER or EMERGENCY ROOM

Cont’d…• Cases of suspected or evident sexual assault.• Cases of suspected or evident criminal abortion.• Cases of unconsciousness where cause is not natural/ not clear• Cases of suspected self-infliction of injuries or attempted suicide• Death /arrest in the operation theatre• Brought dead to the casualty/Accident and Emergency dept / deaths occurring within 24 hours of hospitalization without establishment of diagnosis

PROCEDURE• In the casualty - first priority is to save the life

of the patient. • He should do everything possible to resuscitate

the patient and ensure that he is out of danger.

• All legal formalities stand suspended till this is achieved.

PRECAUTIONS

• Consent• Confidentiality • Collection and preservation of

samples• Preparation of medico-legal reports

in duplicate

PolytraumaAirway – and total spine controlBreathing – and ventilatory support.Circulation – with haemorrhage control.Disability – brief neurological evaluation.Exposure – completely undress the patient

AIRWAY Mandatory intubation in • GCS < 9• Severe facial injury or bleeding.• Severe facial or neck burns

Anticipate airway problems in all patients with trauma to:

• Head & Neck• Upper Thorax

AIRWAY - Cont’d• Restlessness, decreased LOC = Hypoxia

until proven otherwise• Oxygenate, Look for cause• Oxygen is useless if patient isn’t ventilatingDanger Signs• Respirations <10• Respirations >24• Decreased tidal volume• Labored breathing

BREATHING AND VENTILATION• Rapid assessment of respiratory rate, Spo2,

trachea , chest expansion and auscultation. • Tension pneumothorax & haemothorax - immediate

needle thoracocentesis Always exclude the following 1) Tension pneumothorax 2) Massive haemothorax 3) Open pneumothorax 4) Flail chest 5) Pericardial tamponade

CIRCULATION & HAEMORRHAGE CONTROL

• Restlessness and anxiety especially with pallor, tachycardia, or slow capillary refill =

• Falling BP = Late sign of shock

• Don’t treat a falling BP - Prevent It!!

SHOCK

Cont’d

• If shock present without external bleeding, think:– Thoracic or abdominal bleed– Pelvic fracture– Multiple long bone fractures– Tension pneumothorax– Cardiac tamponade

Cont’d• Isolated head trauma does NOT cause

decreased BP in adults• Look for injuries of:

– Chest– Abdomen– Pelvis– Major long bones

CONT’‘ D• Orthopedic injury usually NOT life-

threatening• Exceptions:

– Pelvic fracture– Femur fractures

• Assess, treat proximal to distal

• Insert 2 large IV cannula.

CONT ‘ D

• If you don’t know the diagnosis. . .

Open, clear, maintain airwayMaximize oxygenation, ventilation

Maximize perfusion

TRAUMA CARE CONCLUSIONS• Definitive Treatment = Surgeon’s Knife

• Trying to field-stabilize unstable trauma = Ultimate Stabilization

• Minimum time on scene ; Maximum treatment in route

• Patient MUST go to facility able to continue care appropriately

• Closest facility, facility preferred by family is NOT necessarily most appropriate

DEATH

TRAUMA CENTRE

When Trauma Deaths Occur

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<1 hour 1-3 hours 4 to 6 weeks

“The Trimodal Distribution

Immediate Deaths(<1 hour)

• Loss of Airway• Brain Stem Laceration• High C-Spine Lesion• Aortic/Heart Rupture

• What can be done about these deaths?

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Early Deaths (1-3 hours )

• Epidural Heamatoma• Subdural Heamatoma• Hemo/Pneumothorax• Intra-abdominal Bleeding• Pelvic Fractures• Femur Fractures• Multiple Long Bone Fractures

Why do these patients die?

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Late (2-4 weeks)

• Sepsis

• Multiple Organ System Failure

How can these deaths be avoided?

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Trauma Care Conclusions• Definitive Trauma Care = Surgeon’s Knife

• Short time to surgery = Improved survival

• EMS improves survival by:– Recognizing critical trauma– Supporting oxygenation, ventilation, perfusion– Transporting rapidly to definitive care

“The golden hour” concept -the platinum few minutes

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RECOGNIZING THE GOLDEN HOUR AND PLATINUM MINUTES

!• Where should the patient go?

The most appropriate

facility Not necessarily the closest

one!

FEW CASES

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CONT’D

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BACK TO NORMAL WAYS!

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THE EDHs

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THE EDHs cont’d

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POISONING AND DRUG OVERDOSES

• 12% of all ICU admissions in India • 30% of patients requiring ventilatory support

• 75% of all admissions due to poisonings

• MORE THAN 50% OF ICU ADMISSIONS IN CAUVERY HOSPITAL REQUIRING VENTILATION

MANAGEMENTGeneral Measures• Decontamination of the skin is very important and

done thoroughly. • Forced emesis if the patient is fully awake or

through a gastric lavage.

• 0.5-1 g/kg activated charcoal every 4 h. Sodium sulfate or sorbitol can be used as a cathartic.

• Serotonin adipinate

Cont’d• The airway - adequate oxygenation should be

ensured.

• Atropine can precipitate ventricular arrhythmia in hypoxic patients.

• Early use of atropine - reduces respiratory secretions,

improve muscle weakness, and thereby improve oxygenation.

• Careful observation - as these patients are prone to respiratory failure during the acute phase and intermediate syndrome.

Things to look for…..The important parameters to be monitored on a

regular basis are

• Symptoms of ocular muscle involvement (e.g.;

diplopia),• Neck muscle weakness• Tidal volume / vital capacity/RR• Single breath count• Arterial blood gas estimation or pulse oximetry.

Specific therapy Anticholinergic Agent• Mainstay of treatment • Atropine can be started initially as a 2.4mg IV

bolus and then repeated at doses of 2-5 mg IV bolus every 5-15 min until atropinization is achieved.

• Most commonly used regimen is 0.2mg/kg/hour titrated to desired effect

Target end-points for Atropine therapy

• Heart rate >80/ min, Systolic blood pressure >80

• Dilated pupils

• Dry axillae ,Drying of all secretions

• Chest clear of secretions and crepts.

Oximes• PRALIDOXIME (2-PAM).

– OPCs bind and phosphorylate one of the active sites of AChE and inhibit the functionality of this enzyme.

– Oximes bind to the OP causing the compound to break its bond with AChE – REACTIVATION.

– AGEING IS A CONCERN.

• The main therapeutic effect of pralidoxime is due to recovery of N-M transmission at nicotinic synapses.

• However, oximes also enhance cholinesterase activity at muscarinic sites decreasing the requirement for atropine.

Supportive measures• Never forget co-existing diseases and medical

conditions

• Primarily supportive

• VAP-protocol

• DVT prophylaxis and thromboembolism prevention

• “ FAST HUG ME ”

Sample spectrum of op poisoning

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BURNS• Classification-Degree and percentage of

burnsMajor burns• 3rd degree or full thickness involving more than 10% BSA

• 2nd degree or partial thickness involving more than 25% BSA

• Burns involving face, hands and feet • Inhalational /chemical /electric burns and burns in pts with

co-existing medical diseases.

ABC IN BURNS• Secure airway early, as intubation is likely to be

difficult once edema has set in.

• In a child nasal intubation is preferred over oral

• Smoke inhalation and ALI

• CO poisoning.

• Eschorotomies

circulation• Parkland formula 4ml/kg/% of BSA burnt 50% of it in first 8hrs

25% each in remaining 8 hrs each

• Mount vernon regimen

• Brook’s formula

• Modified brook’s regimen

DROWNING• ABCs – maintain airway at earliest

• Always keep in mind drug and alcohol intoxication

• Beware of prognosticating only with pupil size and reaction

• Hypothermia ----cerebroprotective!!!

• Consider mannitol and diuretics

Attempted Hanging• ABCs • Secure airway, cervical spine control• Liberal use of steroids• Cerebral edema and hypoxia– major

determinant• Mannitol• Supportive measures.

Description of Ligature mark

INTENSIVIST - ICU !!!

Oh. GOD!!! NO WAY

Wish you Happy new year