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 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

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