ED Orientation Part 2: B and C

ED Orientation Part 2

Breathing + Circulation

Asthma

Bad asthma

What are you going to do?

Bad asthmaSalbutamol - back to back nebs – oxygen driven

Ipratropium neb

Steroid eg prednisone

IV salbutamol

BiPAP eg 10/2cmH2O (continue nebs via BiPAP)

Rarely ketamine – senior doc

Nebulised adrenaline

IV magnesium is probably out for adults (but life threatening asthma was excluded from the trial), probably works for kids http://stemlynsblog.org/2013/05/jc-does-magnesium-work-in-asthma-st-emlyns/

CXR +/- or U/S to rule out pneumothorax

COPD

Bad COPD What are you going to do?

COPD

Work out ceiling of care

Nebuliser

BiPAP eg 10/5.

Continue neb via BiPAP

Steroids

Antibiotics if productive cough

Wheezy babies

Working hard to breath

What are you going to do?

Wheezy babies

< 3 months consider congential heart disease

< 1 year = bronchiolitis

> 1 year = wheezy bronchitis, or if recurrent = asthma

Any age: consider foreign body - but very rare

Wheezy babies

Rinse nose with saline

Oxygen in sats < 92%

< 6 months: don't use ß agonist or steroids

< 1 year: if family Hx of atopy try ß agonist6 puffs via spacer q20 min. If no objective improvement stop usingNo steroids

> 1 year and working very hard or hypoxicß agonist and steroids

Wheezy babies

Admit if

RR > 60

Unable to feed

Sats < 92% on RA

Poor social situation

CCF

Bad CCF

What are you going to do?

CCF

GTN 1-2 puffs SL PRN q5min if BP will tolerate

BiPAP or CPAP eg 10/5

? Frusemide if fluid overloaded

GTN patch or infusion if requiredCan't do infusions on ward :-(

Early use of ACEI

The highest rib space that can be easily felt in the axilla.

• Spontaneous: long needles eg central line needle, 16 G angiocath

• Trauma: finger thoracostomy: big cut with a scalpel, then a finger in the hole to ensure you are in the space.

• http://lifeinthefastlane.com/2011/04/own-the-chest-tube/

• “Moderate” pneumothorax can be aspirated eg via long IV cannula but …Most often we are putting in a 14Fr chest drain using Seldinger technique

• Video: http://www.cookmedical.com/cc/datasheetMedia.do?mediaId=4490&id=5392

• Major trauma we will usually put in a 32Fr chest tube by open technique - but this will change over time - to smaller Seldinger drains. – We have 32Fr Seldinger sets.

• If you have time - lots of long acting local anaesthetic into the chest wall and pleural space

• + IV analgesia / procedural anaesthesia

C

• All ECGs read by doctor as soon as they are taken

• Written interpretation

• Time

• Legible name

• We will go through some key ECGs in the ECG session and the syncope session

STEMI

• Thrombolyse in ED

• Streptokinase or Tenectoplase

• Follow the ACS pathway

Syncope or new seizure ECG

• See http://emtutorials.com/2013/05/syncope-beardsell-semep/

Temporary treatment for hypotension

Push dose pressors

• Phenylephrine: pure alpha = vasoconstrictor without tachycardia

• 10mg of phenylephrine in 100ml normal saline = 100µg/ml

• 2ml = 200µg works in a few minutes, lasts about 5 minutes

Push dose pressors

• Adrenaline/epinephrine

• Vasoconstriction + increased cardiac contractility

• Risk of tachyarrythmia

• 1 ml of 1:10,000 (100mcg) made up to 10ml with normal saline = 10mcg/ml 0.5-2ml push

Tox ECG

• Specific things to look at on the ECG of a patient with a potential overdose.

• These are covered in the tox talks Eg http://emtutorials.com/2013/05/toxicology-for-pgy12/

Shock• No single sign or test

• Hypotension

• Increased capillary refill time

• Shut down peripheries

• Raised lactate

• Tachypnoea

• Tachycardia

• Decreased urine output (get a catheter in early)

• (+/- IVC filling and cardiac contractility by u/s)

Types of Shock?

• Volume loss – eg haemorrhage, 3rd spacing

• Obstruction – eg PE, tamponade

• Pump failure – eg MI, CCB overdose, sepsis, valve pathology

• Vasodilation – eg sepsis, overdose, anaphylaxis, neurogenic

Shock

• NZ is a civilised country and so very little penetrating trauma

Shock

• Use all your clinical skills to work out what is going on

• Consider a wide range of causes.

• All hypotension in trauma is not hypovolaemia– Pneumothorax– Tamponade– Neurogenic shock (diagnosis of exclusion)

• Use ultrasound: pneumothorax, blood around heart, blood in abdo

Haemorrhagic shock

• Trauma – Haemorrhage

• on the bed, • in chest, • abdo, • pelvis, • long bone

– Tension pneumothorax, tamponade– Clinical exam + ultrasound + XRay +/- CT

Haemorrhagic shock

• Use blood products early

• Minimise use of crystaloid / colloid

• O-negative blood available in minutes

• FFP takes half an hour to thaw - request early

• Platelets come by taxi from 1 hour away

• Use tranexamic acid 1g IV over 10 minutes then 1g IV over 8 hours

Non haemorrhagic shock

• Treat specific cause

• If not sure: 500ml - 1L of saline likely to help

IV Access

• If you have failed to get an IV line in a patient after 2 goes be nice to yourself and the patient and get someone else to try.– We all have off days.

• Remember the interosseous needle for adults or kids

http://www.vidacare.com/admin/files/T427RevC-Insert-RemPoster.pdf