ED Orientation Part 2: B and CPresentation 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.
“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
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)
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 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