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ED orientation

ED orientation

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ED orientation

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  1. ED orientation Crash Course in Emergency Medicine For junior ED docs Preparation ABCs

  2. Not comprehensive Just the things you really need to know / will scare the crap out of you

  3. Ask a nurse

  4. If you are thinking “Should I discuss this with a senior?” ...

  5. We are very lucky to get ambo call about most serious cases

  6. The 5 Ps of Preparation People Place Protection Plant Plan

  7. People Get extra hands first – rate limiting step Get some extra help in – if in doubt ask the nurses ED consultant Anaesthetist/reg Surgical registrar XRay CT Lab Extra nurses Assign roles • eg team leader, airway doc/nurse, examining doc, lines + procedures doc/nurse

  8. Place Create a space for them Move people out of resus Move people out of ED

  9. Personal Protective Equipment XRay gown Goggles Masks Lead apron Apron/gown Gloves

  10. Plant = equipment and drugs Prepare ultrasound machine, blood, drugs eg analgesics, airway equipment etc as required based on the information you have

  11. 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

  12. ABCDEfG Can be applied to 95% of what we see in ED Use it for your approach and your documentation

  13. A + ?

  14. Airway + c-spine Spinal precautions initially for any moderate - major trauma. Stabilise c-spine with collar Grip head and shoulders when moving Controlled slide on sliding board OK

  15. 2 best airway tools?

  16. Basic airway maneuvers • What are they?

  17. Jaw thrust - mainly we do this one • Chin lift • Head tilt

  18. Basic airway adjuncts • What are they? • What size do you use?

  19. OPA = Guedel • Size from corner of mouth to angle of jaw • Insert upside down in adult, then rotate • Insert right way up in kids • If the patient tolerates an OPA that’s a fairly good indication they aren’t protecting their airway and probably need to be intubated • Image http://www.aic.cuhk.edu.hk/web8/0190_Guedel_airway_sizing.jpg

  20. NPA • From nostril to tragus LMA • Weight written on packet. • 5: adult male • 4: adult female

  21. Bag-Valve-Mask • Essential skill • Mask fits over bridge of nose and below lower lip but not under chin • Little finger behind ramus of mandible to lift jaw forward • 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

  22. 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)

  23. 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

  24. Stridor Bad stridor - what are you going to do?

  25. Stridor • 5mg nebulised adrenaline / epinephrine = 5ml ampules of 1:1,000 (unless < 10kg -> 0.5ml/kg of 1,000) • Steroid • egdexamethasone 0.6mg/kg (max 12mg) • PO, IM, IV

  26. Anaphylaxis • Bad anaphylaxis • What are you going to do?

  27. Anaphylaxis • Mild cases may respond to just nebulised adrenaline, IV fluids, steroids • BUT if in doubt: 0.5mg IM adrenaline + the above • + steroids egdexamethasone as for stridor • +/- IV adrenaline eg 5-20mcg (eg 1mg in 1L Normal saline = 1mcg/ml) q 5min or push dose pressorshttp://emcrit.org/podcasts/bolus-dose-pressors/ • +/- Antihistamines

  28. Can't ventilate What are you going to do?

  29. Can't ventilate • Surgical cricothyroidotomy or needle cric in kids • Surgical: scalpel - bougie– ETT • http://www.emrap.tv/index.php?option=com_content&view=article&id=2274:EMRAPTV94-Cric-Bougie • Airway 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 animals • http://www.surgeons.org/for-health-professionals/register-courses-events/skills-training-courses/emst/ • http://www.airwayskills.co.nz/page.php?3

  30. http://www.emrap.tv/index.php?option=com_content&view=article&id=2274:EMRAPTV94-Cric-Bougiehttp://www.emrap.tv/index.php?option=com_content&view=article&id=2274:EMRAPTV94-Cric-Bougie

  31. Big tongue • Patient with idiopathic tongue angioedema • What are you going to do?

  32. Tox

  33. Shock • No single sign • Hypotension • Increased capillary refill time • Shut down peripheries • Raised lactate • Tachypnoea • Tachycardia • (+/- IVC filling and cardiac contractility by u/s)

  34. Shock • Multiple causes • Volume loss eg haemorrhage, 3rd spacing • Obstruction eg PE, tamponade • Pump failure eg MI, CCB overdose, sepsis • Vasodilation eg sepsis, overdose, anaphylaxis

  35. Shock NZ is a civilised country and so very little penetrating trauma

  36. 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

  37. Haemorrhagic shock • Early use of blood products • O neg available immediately • 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

  38. Haemorrhagic shock • Trauma • Heamorrhage on the bed, in chest, abdo, pelvis, long bone • Clinical exam + ultrasound + XRay +/- CT • External haemorrhage -> tourniquet or pressure • Pelvis or long bone - stabilise with binder or splint • Chest -> surgeon • Abdo -> surgeon but often conservative Mx

  39. Non haemorrhagic shock • Treat specific cause • If not sure: 500ml - 1L of saline likely to help