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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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Presentation Transcript
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
when suddenly
When suddenly …

“Is there a doctor on the plane?

your

picture

here

slide6
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 …

slide8
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 …

slide10
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
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
slide31
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)
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