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CRITICAL CONCEPTS LSU SCHOOL OF MEDICINE SENIOR ROTATION 2012-13 PowerPoint PPT Presentation


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http://www.medschool.lsuhsc.edu/emergency_medicine/critical_concepts_rotation.aspx. CRITICAL CONCEPTS LSU SCHOOL OF MEDICINE SENIOR ROTATION 2012-13. WELCOME TO CRITICAL CONCEPTS. ROTATION OBJECTIVES:

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CRITICAL CONCEPTS LSU SCHOOL OF MEDICINE SENIOR ROTATION 2012-13

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Http www medschool lsuhsc edu emergency medicine critical concepts rotation aspx

http://www.medschool.lsuhsc.edu/emergency_medicine/critical_concepts_rotation.aspx

CRITICAL CONCEPTSLSU SCHOOL OF MEDICINESENIOR ROTATION 2012-13


Welcome to critical concepts

WELCOME TO CRITICAL CONCEPTS

ROTATION OBJECTIVES:

  • Provide all senior students with exposure to acute and critical care concepts in a variety of learning modalities. 

  • Review and reinforce diagnostic and management skills in common and/or critical disease entities and procedures encountered in a range of specialties.

  • Prepare senior students for their new roles as resident physicians with direct patient care and health care team responsibilities.


Underlying principle

UNDERLYING PRINCIPLE

  • Every physician – regardless of specialty – should know how to manage acutely ill, undifferentiated patients with a variety of emergent conditions


Clinical scenarios case 1

CLINICAL SCENARIOS: Case 1

JUNE 5, 2013


When suddenly

When suddenly …

“Is there a doctor on the plane?

your

picture

here


Critical concepts lsu school of medicine senior rotation 2012 13

A 63 year old woman traveling alone in first began shouting incoherently and wandering around about ten minutes ago. Suddenly, she slumps forward and becomes unresponsive.

The flight attendant hands you a medical bag. You are able to feel a weak radial pulse at approximately 110 beats/minute and note a respiratory rate of 8 breaths/minute.


Clinical scenarios case 2

CLINICAL SCENARIOS: Case 2

JULY 1, 2013

When suddenly … your pager goes off …


Critical concepts lsu school of medicine senior rotation 2012 13

A 60 year old man admitted to the floor got up to go to the restroom. Suddenly, he fell back into bed and became unresponsive.

The floor nurse goes out to find a code cart. You are able to feel a weak radial pulse at approximately 120 beats/minute and note a respiratory rate of 10 breaths/minute.


Clinical scenarios case 3

CLINICAL SCENARIOS: Case 3

October 10, 2013

You are on your EM rotation on a busy night shift when …


Critical concepts lsu school of medicine senior rotation 2012 13

EMS brings in a 57 year old man who was an unrestrained driver in a rollover MVC with multiple cars. He was not responsive at the scene.

Vital signs in the ambulance were HR 115, BP 100/60, and RR 10. All of the EM residents are busy working up the other cars’ passengers.


What now

WHAT NOW??

  • What would your immediate actions be

    • In the air?

    • If/when this happens to you on your first day of internship?

    • If you are the first medical professional caring for an acutely ill/injured patient?

  • FOR EACH CASE - LIST 5 OF THE FOLLOWING:

    • Initial actions

    • Possible diagnoses

    • Management/treatment steps


Management of the acutely ill patient

MANAGEMENT OF THE ACUTELY ILL PATIENT

  • Based on the principles of identifying and treating the immediate, life-threatening conditions first

  • All other considerations come second

  • KEEP IT SIMPLE


Primary survey

PRIMARY SURVEY

VITAL SIGNS = CRITICAL IMPORTANCE

HR

RR

BP

Temp

Pulse Ox


Primary survey1

PRIMARY SURVEY

A – airway evaluation

  • Are there any signs of obstruction?

    • FB

    • Masses

    • Trauma

    • TONGUE


Interventions

INTERVENTIONS

  • RELIEVE THE OBSTRUCTION before moving on

    • Finger sweep

    • Chin tilt/head lift or jaw thrust

    • Repositioning

    • Suctioning/hemorrhage control

  • FUTURE AIRWAY PROTECTION?


Primary survey2

PRIMARY SURVEY

  • B – breathing, oxygenation & ventilation

    • Is the patient able to sufficiently oxygenate and/or ventilate?

    • Look for

      • Agitation/restlessness

      • Tachypnea/use of accessory muscles

      • Bradypnea/apnea

      • Breath sounds on BOTH sides

      • Tracheal deviation?

      • JVD?


Primary survey3

PRIMARY SURVEY

  • Life threatening conditions requiring immediate intervention

    • Tension PTX

    • Flail chest

    • Respiratory failure/distress

      • Primary pulmonary issue

      • Consequence of underlying disorder


Intervention

INTERVENTION:

  • Assisted oxygenation/ventilation through

    • Supplemental O2 (how much & how?)

    • Proper bag-valve-mask

    • Non-invasive positive pressure ventilation

    • Intubation (RSI)


Primary survey4

PRIMARY SURVEY

  • C – circulatory status

    • Assess for PULSES (bilaterally) and heart tones

    • Any obvious bleeding?

    • Other s/s:

      • MS changes

      • Cool, pale extremities

      • Capillary refill

      • BP/HR – shock index


Primary survey5

PRIMARY SURVEY

  • Life threatening conditions requiring immediate intervention

    • Shock states:

      • Hypovolemic?

      • Cardiogenic?

      • Distributive?

      • Obstructive?

    • Active hemorrhage


Intervention1

INTERVENTION

  • Venous access (large bore/CVC)

  • Administration of blood or fluid products in rapid boluses

  • Target to specific types of shock:

    • Cardiogenic – inotropes, BP support, procedures

    • Sepsis (distributive) – EGDT, source control

    • Obstructive (PE/tamponade)

    • Anaphylactic – epi, antihistamines


Primary survey6

PRIMARY SURVEY

  • D – disability assessment

    • Mental status/level of consciousness

    • Gross neurologic exam

    • Pupils

    • GCS if trauma


Intervention2

INTERVENTION

  • Prompt imaging as warranted (trauma – hemorrhage or fracture; medical – CVA/mass)

  • Prompt Neuro specialist involvement if appropriate

  • Reversal/supportive care if toxidrome

  • Consider likelihood of airway protection (“GCS less than 8 = intubate”)


Primary survey7

PRIMARY SURVEY

  • E – FULL exposure

    • Every inch of the patient is surveyed and documented for obvious life threats

    • Occult traumatic injury

    • Infectious sources

    • Rashes/skin changes

    • Medications/patches


Interventions1

INTERVENTIONS

  • Imaging/tests/treatment based on findings

  • Removal of any offending agent


After stabilization

After stabilization …

  • Brief, targeted HPI/PMH etc. (“AMPLE”)

  • REASSESSMENT OF VITAL SIGNS and success of any intervention

  • Detailed testing

  • Longer-term treatment and management

  • Secondary survey: FULL PHYSICAL!


Goals

GOALS

  • … in the care of the undifferentiated patient:

    • Identify life-threatening processes

    • Immediate stabilization

    • Consideration of most serious and most likely diagnoses

    • Initiation of definitive treatment and care

    • Utilization of all available resources when appropriate


Don t be afraid

DON’T BE AFRAID …

This is fun!


Rotation housekeeping

ROTATION HOUSEKEEPING

  • Course structure and expectations;

    • 1 didactics week

    • 2 EM weeks

    • 1 ICU week

  • You are expected to be an active participant in all parts of the course, and a full member of each team

    (consider yourselves acting interns)


Your goals

YOUR GOALS

  • What should you get out of this?

    • Expanded skills and knowledge base from 3rd year

    • Application of those skills/knowledge to more complicated/critically ill patients

    • Increased exposure to/experience with common and emergent procedures & interventions

    • More sophisticated understanding of disease complexity & health systems management


Critical concepts lsu school of medicine senior rotation 2012 13

WHO

WHAT

WHERE

WHEN

  • Most of you are here:

  • We want to move you here:

REPORTER

HOW

WHY

WHAT NEXT?

INTERPRETER

MANAGER


Didactics week

DIDACTICS WEEK

  • Please read assigned material on website prior to each session … come prepared to discuss!

  • Each of the 8 specialties has designed their own interactive module on what they perceive to be most important in managing their most critical or common emergencies

  • Each module requires a faculty/preceptor signature


Icu rotation

ICU ROTATION

  • You are an active part of the ICU team and expected to have direct patient care and documentation duties

  • You should participate in family and team discussions of care plans

  • Details will differ between ICUs

  • Information on where/when to report to ICUs – see CC website under “Didactics Schedule & ICU Information”*

    *TICU students – please contact fellows for time/place to meet prior to starting the week


Em rotation

EM ROTATION

  • Again, you are expected to have direct patient care responsibilities as part of the EM team

  • Please read the assigned EM readings during your 2 week block

  • While on the EM portion of the rotation, you are expected to attend EM student lectures and labs


Case procedure logs

CASE & PROCEDURE LOGS

  • During your EM block, please log all patient encounters and procedures that you observe, assist with, and/or perform into New Innovations

  • This is a way to begin to build your medical portfolio


Responsibilities

RESPONSIBILITIES

  • BE ON TIME … for all sessions, rounds, and shifts

  • Adhere to the school honesty policy at all times

  • Be properly supervised in all educational and clinical settings and duties


Evaluation methods

EVALUATION METHODS

  • Final grade is based on:

    • End of rotation on-line exam, derived from:

      • EM and specialty-specific reading (all online on website)

      • Social media content

      • Didactic session lectures and labs

    • Professionalism assessment during clinical rotation

  • H/HP/P/F system

  • Either component can be remediated if necessary


Attendance policy

ATTENDANCE POLICY

  • Students may miss 2 days of the rotation FOR INTERVIEWS ONLY:

    • During EM block – may miss 1 ED shift and one “free” day

    • During ICU block – if 2 ICU days are missed, they must be remediated the weekend before or after (in order to have a full week of ICU)

    • DIDACTICS DAYS MAY NOT BE MISSED

  • Please contact Dr. English or Dr. Avegno for attendance questions


Forms

FORMS

  • Please turn in evaluation form to Jennifer Jeansonne, course coordinator, upon completion of the rotation (room 615)


Now enjoy the course

NOW … ENJOY THE COURSE!


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