ED Orientation Part 2: B and C
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ED Orientation Part 2: B and C






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    ED Orientation Part 2: B and C ED Orientation Part 2: B and C Presentation Transcript

    • ED Orientation Part 2Breathing + Circulation
    • AsthmaBad asthmaWhat are you going to do?
    • Bad asthmaSalbutamol - back to back nebs – oxygen drivenIpratropium nebSteroid eg prednisoneIV salbutamolBiPAP eg 10/2cmH2O (continue nebs via BiPAP)Rarely ketamine – senior docNebulised adrenalineIV magnesium is probably out for adults (but life threateningasthma was excluded from the trial), probably works for kidshttp://stemlynsblog.org/2013/05/jc-does-magnesium-work-in-asthma-st-emlyns/
    • CXR +/- or U/S to rule out pneumothorax
    • COPDBad COPD What are you going to do?
    • COPDWork out ceiling of careNebuliserBiPAP eg 10/5.Continue neb via BiPAPSteroidsAntibiotics if productive cough
    • Wheezy babiesWorking hard to breathWhat are you going to do?
    • Wheezy babies< 3 months consider congential heart disease< 1 year = bronchiolitis> 1 year = wheezy bronchitis, or if recurrent =asthmaAny age: consider foreign body - but very rare
    • Wheezy babiesRinse nose with salineOxygen in sats < 92%< 6 months: dont use ß agonist or steroids< 1 year: if family Hx of atopy try ß agonist6 puffs via spacer q20 min.If no objective improvement stop usingNo steroids> 1 year and working very hard or hypoxicß agonist and steroids
    • Wheezy babiesAdmit ifRR > 60Unable to feedSats < 92% on RAPoor social situation
    • CCFBad CCFWhat are you going to do?
    • CCFGTN 1-2 puffs SL PRN q5min if BP will tolerateBiPAP or CPAP eg 10/5? Frusemide if fluid overloadedGTN patch or infusion if requiredCant do infusions on ward :-(Early use of ACEI
    • The highest rib space that can be easily felt inthe axilla.Spontaneous: long needles eg central lineneedle, 16 G angiocathTrauma: finger thoracostomy: big cut with ascalpel, then a finger in the hole to ensure youare in the space.
    • http://lifeinthefastlane.com/2011/04/own-the-chest-tube/
    • “Moderate” pneumothorax can be aspirated egvia long IV cannula but …Most often we areputting in a 14Fr chest drain using SeldingertechniqueVideo:http://www.cookmedical.com/cc/datasheetMedia.do?mediaId=4490&id=5392Major trauma we will usually put in a 32Fr chesttube by open technique - but this will changeover time - to smaller Seldinger drains.We have 32Fr Seldinger sets.
    • If you have time - lots of long acting localanaesthetic into the chest wall and pleural space+ IV analgesia / procedural anaesthesia
    • C
    • All ECGs read by doctor as soon as they aretakenWritten interpretationTimeLegible nameWe will go through some key ECGs in the ECGsession and the syncope session
    • STEMIThrombolyse in EDStreptokinase or TenectoplaseFollow the ACS pathway
    • Syncope or new seizureECGSee http://emtutorials.com/2013/05/syncope-beardsell-semep/
    • Temporary treatment forhypotension
    • Push dose pressorsPhenylephrine: pure alpha = vasoconstrictor withouttachycardia10mg of phenylephrine in 100ml normal saline =100µg/ml
    • Push dose pressorsAdrenaline/epinephrineVasoconstriction + increased cardiaccontractilityRisk of tachyarrythmia1 ml of 1:10,000 (100mcg) made up to10ml with normal saline = 10mcg/ml 0.5-2ml push
    • Tox ECGSpecific things to look at on the ECG of a patientwith a potential overdose.These are covered in the tox talks Eghttp://emtutorials.com/2013/05/toxicology-for-pgy12/
    • ShockNo single sign or testHypotensionIncreased capillary refill timeShut down peripheriesRaised lactateTachypnoeaTachycardiaDecreased urine output (get a catheter in early)(+/- IVC filling and cardiac contractility by u/s)
    • Types of Shock?Volume losseg haemorrhage, 3rd spacingObstructioneg PE, tamponadePump failureeg MI, CCB overdose, sepsis, valve pathologyVasodilationeg sepsis, overdose, anaphylaxis, neurogenic
    • ShockNZ is a civilised country and so very littlepenetrating trauma
    • ShockUse all your clinical skills to work out what isgoing onConsider a wide range of causes.All hypotension in trauma is not hypovolaemiaPneumothoraxTamponadeNeurogenic shock (diagnosis of exclusion)Use ultrasound: pneumothorax, blood aroundheart, blood in abdo
    • Haemorrhagic shockTraumaHaemorrhageon the bed,in chest,abdo,pelvis,long boneTension pneumothorax, tamponadeClinical exam + ultrasound + XRay +/- CT
    • Haemorrhagic shockUse blood products earlyMinimise use of crystaloid / colloidO-negative blood available in minutesFFP takes half an hour to thaw - request earlyPlatelets come by taxi from 1 hour awayUse tranexamic acid 1g IV over 10 minutes then1g IV over 8 hours
    • Non haemorrhagic shockTreat specific causeIf not sure: 500ml - 1L of saline likely to help
    • IV AccessIf you have failed to get an IV line in a patientafter 2 goes be nice to yourself and the patientand get someone else to try.We all have off days.Remember the interosseous needle for adults orkids
    • http://www.vidacare.com/admin/files/T427RevC-Insert-RemPoster.pdf