ED orientation Crash Course in Emergency Medicine For junior ED docs Preparation ABCs
Feb 23, 2016
ED orientation
Crash Course in Emergency Medicine
For junior ED docs
PreparationABCs
Not comprehensive Just the things you really need to know / will scare the
crap out of you
Ask a nurse
If you are thinking “Should I discuss this with a senior?” ...
We are very lucky to get ambo call about most serious cases
The 5 Ps of Preparation
PeoplePlaceProtectionPlant Plan
People
Get extra hands first – rate limiting stepGet some extra help in – if in doubt ask the nursesED consultantAnaesthetist/regSurgical registrarXRayCTLabExtra nursesAssign roles• eg team leader, airway doc/nurse, examining
doc, lines + procedures doc/nurse
Place
Create a space for themMove people out of resusMove people out of ED
Personal Protective Equipment
XRay gownGogglesMasksLead apronApron/gownGloves
Plant = equipment and drugs
Prepare ultrasound machine, blood, drugs eg analgesics, airway equipment etc as required based on the information you have
Plan
Talk through your plan based on what you know with the team
As you think out loud others can chip in with things you may not have thought of
Gets everyone on the same page
But remember the plan may change rapidly
ABCDEfG
Can be applied to 95% of what we see in ED
Use it for your approach and your documentation
A + ?
Airway + c-spine
Spinal precautions initially for any moderate - major trauma.
Stabilise c-spine with collar Grip head and shoulders when movingControlled slide on sliding board OK
2 best airway tools?
Basic airway maneuvers
What are they?
Jaw thrust - mainly we do this one
Chin lift
Head tilt
Basic airway adjuncts
What are they?
What size do you use?
OPA = Guedelo Size from corner of mouth to angle of jaw
o Insert upside down in adult, then rotateo Insert right way up in kidso If the patient tolerates an OPA that’s a fairly good
indication they aren’t protecting their airway and probably need to be intubated
o Image http://www.aic.cuhk.edu.hk/web8/0190_Guedel_airway_sizing.jpg
NPAo From nostril to tragus
LMAo Weight written on packet. o 5: adult maleo 4: adult female
Bag-Valve-Mask
o Essential skill
o Mask fits over bridge of nose and below lower lip but not under chin
o Little finger behind ramus of mandible to lift jaw forward
o Use a two hand grip on face and mask if needed – get someone else to squeeze the bag if needed
Image: https://www.proceduresconsult.jp/UploadedImages/pcj_0010_00000026_100000_large.jpg
Anaesthetic drugs
Only with a Senior Medical Officer at the bedside.
(But our system allows heroic doses of narcotics and benzodiazepines – which are probably more dangerous. Just don't send someone to Xray with a big dose of opioids on board)
ETT
So for you guys flying solo, an ETT is only for dead people.
LMA very acceptable (for anyone with no gag reflex
If you are intubating we have a video laryngoscope
Stridor
Bad stridor - what are you going to do?
Stridor
5mg nebulised adrenaline / epinephrine = 5ml ampules of 1:1,000 (unless < 10kg -> 0.5ml/kg of 1,000)
Steroid eg dexamethasone 0.6mg/kg (max 12mg)PO, IM, IV
Anaphylaxis
Bad anaphylaxis
What are you going to do?
Anaphylaxis
Mild cases may respond to just nebulised adrenaline, IV fluids, steroids
BUT if in doubt: 0.5mg IM adrenaline + the above
+ steroids eg dexamethasone as for stridor
+/- IV adrenaline eg 5-20mcg (eg 1mg in 1L Normal saline = 1mcg/ml) q 5min or push dose pressors http://emcrit.org/podcasts/bolus-dose-pressors/
+/- Antihistamines
Can't ventilate
What are you going to do?
Can't ventilate
Surgical cricothyroidotomy or needle cric in kidsSurgical: scalpel - bougie – ETThttp://www.emrap.tv/index.php?option=com_content&view=article&id=2274:EMRAPTV94-Cric-BougieAirway study day twice a year in Whanganui: cric's, chest drains etc
on dead sheep.EMST or Auckland Airway Course to do same on anaesthetised
animalshttp://www.surgeons.org/for-health-professionals/register-courses-events/skills-training-courses/emst
/http://www.airwayskills.co.nz/page.php?3
http://www.emrap.tv/index.php?option=com_content&view=article&id=2274:EMRAPTV94-Cric-Bougie
Big tongue
Patient with idiopathic tongue angioedema
What are you going to do?
Tox
Shock
No single sign
HypotensionIncreased capillary refill timeShut down peripheriesRaised lactateTachypnoeaTachycardia(+/- IVC filling and cardiac contractility by
u/s)
Shock
Multiple causes
Volume loss eg haemorrhage, 3rd spacingObstruction eg PE, tamponadePump failure eg MI, CCB overdose, sepsisVasodilation eg sepsis, overdose,
anaphylaxis
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.
Ultrasound: pneumothorax, blood around heart, blood in abdo
Haemorrhagic shock
Early use of blood products
O neg available immediatelyFFP takes half an hour to thaw - request
earlyPlatelets come by taxi from 1 hour away
Use tranexamic acid 1g IV over 10 minutes then 1g IV over 8 hours
Haemorrhagic shock
Trauma o Heamorrhage on the bed, in chest, abdo,
pelvis, long boneo Clinical exam + ultrasound + XRay +/- CT
External haemorrhage -> tourniquet or pressurePelvis or long bone - stabilise with binder or splintChest -> surgeonAbdo -> surgeon but often conservative Mx
Non haemorrhagic shock
Treat specific cause
If not sure: 500ml - 1L of saline likely to help