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ED Orientation Part 3: More on circuclation through to self care and study
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ED Orientation Part 3: More on circuclation through to self care and study



Orientation for new ED doctors

Orientation for new ED doctors



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  • What's this what are you going to do?
  • Analgesia and light sedation eg 100mcg fentanyl and 2mg of midazolam)
  • 13 year old boy sudden onset of palpitation
  • 13 year old boy sudden onset of palpitation
  • 30 F sudden onset of palpitation
  • 30 F sudden onset of palpitation
  • VT. complexes don't look like LBBB. Complexes looks quite similar in all leads cf quite different in different in different leads in LBBB

ED Orientation Part 3: More on circuclation through to self care and study Presentation Transcript

  • 1. More ECGs
  • 2. Tachycardias
  • 3. TachycardiasWCT -> syndrhonised (if has a pulse)electrically cardiovert 200J(happens to be WPW AF)
  • 4. Tachycardias
  • 5. TachycardiasVF. 200J unsych. 2 minutes CPR, repeat.Adrenaline after 2 zaps, amiodarone nextcycle etc
  • 6. TachycardiasRecent onset palpitation, Chest pain.
  • 7. TachycardiasRecent onset palpitation, CP, hypotensionRecent onset AF ->Seek and treat any precipitant: sepsis, CCFSynchronised electrical cardioversion 200J
  • 8. TachycardiasChronic AF, CP, hypotension
  • 9. TachycardiasChronic AF, CPSeek and treat precipitant eg CCF, sepsis, hypovolaemiaRate control eg diltiazem 10mg IV, 20mg 15 min later if needed½ dose if hypotensive. May need diltiazem + phenylephrineCheck BP before each dose
  • 10. Tachycardias
  • 11. TachycardiasSinus tachyP waves in V1Best way is to look at monitor - sinus tachy rate varies.SVT does not.
  • 12. Tachycardias
  • 13. TachycardiasSVTVagal manoeuvres: Ice, carotid sinus (if < 60),ValsalvaAdenosine 12, 18, 18mg fast push
  • 14. Tachycardias40 renal patient with CP and SOB
  • 15. TachycardiasHyper K.What are you going to do?Whats your threshold?
  • 16. Hyper K with widened QRSSalbutamol 10mg nebCalcium gluconate 10mmol = 1 ampUrgent dialysisIf delay to dialysis d/w renal unit re insulinand glucose, HCO3, frusemide.
  • 17. Renal failure patientsECG on arrival – look for hyperKFentanyl or oxycodone for analgesia ratherthan morphine or tramadolCAPD patients with belly pain or any signs ofsepsis -> eyeball the dialysate -> cloudy =peritonitis -> intraperitoneal Abs +/- SepsisPathway
  • 18. Tachycardias
  • 19. TachycardiasLBBB + sinus tachy
  • 20. Compare with this
  • 21. BradycardiaHypotensive, pale, faint.What are you going to do?
  • 22. BradycardiaCPR if needed (no pulse, losing consciousness)Fluid load if not overloadedTranscutaneous pacing -> Transvenous pacing.Isoprenaline infusion
  • 23. DSeizuresYou are called to a room where a febrile childhas been seizing for 1 minuteWhat are you going to do?
  • 24. SeizuresReassure everybodyTurn the child on his/her sideWait for seizure to stopsIf seizure last 3 minutes hat are you going todo?
  • 25. SeizuresCheck blood sugar (2 ml/kg of 10% dextrose PRN)BenzodiazepineWe usually use midazolam 0.15mg/kg IV or0.2mg/kg IM. Can also use IN, buccal, rectal.Repeat if still seizing after 5 minutes.
  • 26. ComaCauses?Approach?
  • 27. ComaGo through ABCDEGThen use eg AEIOUTIPSAlcohol and other drugsElectrolytes, encephalopathy (hepatic, hypercapnic, hypertensive (NB kids), infective, endocrine)Inborn errors, intestinal disasterOverdoseUraemiaTrauma, toxinsInfectionPsychiatricSeizure (including non-convulsive and post ictal), Stroke, SOL, snake or spider bite (not in NZ!)
  • 28. ComaManagementVery firm sternal rubRecovery position (unless possibility of spinal trauma)Manage ABCs as requiredGet senior help ? intubate then CT
  • 29. AnalgesiaFentanyl for moderate - severe painLess itch, hypotension, nausea than morphine1µg/kg IV/IO, 1.5-3µg/kg IN, repeat PRNNo diamorph in NZConvert to morphine if needed when pain undercontrolParacetamol load 20mg/kg then 15mg/kgthereafterIbuprofen 10mg/kg
  • 30. AnalgesiaKetamine eg 5-30mg as analgesic50% or 70% nitrous oxideLong acting local anaesthetics (eg bupivocaine2.5mg/kg) – wrists, ribs, clavicles, wristblocks, ring blocks, femoral nerve, fasciailiaca/triple block.Local anaesthetic toxicityIntralipid
  • 31. G: Glucose, Guts (abdo), GynaeHypoglycaemia3-4 Oral glucose tabs then foodIf unable to eat: 2ml/kg 10% glucose
  • 32. GAbdo pain in the elderlyBe afraidLow threshold for bedside u/s for AAALow threshold for CT abdo
  • 33. GynaeßHCG in almost every female of childbearingage who is in EDShock in early pregnancy = ectopic till provenotherwise.Bedside ultrasound for free fluid in abdo.If +ve call gynae, transfuse, tranexamic acid
  • 34. Gynae shockIf unable to do bedside ultrasound-> PV exam - remove POC from cervixIf no products is internal os open?Yes -> miscarriage – see next slideNo -> call gynae +/- urgent ultrasound
  • 35. If shocked + miscarrying in early pregnancyRemove POC from CxMisoprostal 800mg PR or buccallyTranexamic acid 1g IVIf still bleeding ++ -> transfuse and callgynae + theatre (rare)
  • 36. POCMany women from many cultures want tokeep/bury products of conception - dontjust throw POC is the rubbish in the room.
  • 37. Managing your day
  • 38. Managing your dayDont take too many patients at onceTo start with dont have more than 3 active patientsTake breaksHave a lunch break
  • 39. Managing your dayDont take on new patients in your last hour: tidy up yourremaining patients, sign off some labs or XRays andcheck work emails.Handover any remaining patients before you goTrust that your colleagues will be taking good care of yourpatients and let them go.
  • 40. Managing your night
  • 41. Managing your nightHave a napIf that little voice says dont send that patienthome -> keep em, especially after 3amPick the nurses brainsIf you think you should ring a consultant /registrar -> ring em
  • 42. Managing your nightYou will feel your performance improves overyour week of nightsIt doesntYou get worseIf in doubt talk to the boss or keep the patientin
  • 43. Self careInformation overloadWe cant know everythingWe are human and make mistakesAccept yourself and work to improve
  • 44. Self care / being a better docMeditation•http://emtutorials.com/2013/04/mindfulness-for-health-professionals/•Sleep•http://emtutorials.com/2013/04/insomnia-and-sleep/
  • 45. Study45 minutes then take a 15 minute breakhttp://lifeinthefastlane.com/ Links to all free EM teachinghttp://embasic.org/http://www.emrap.org/ $http://emcrit.org/ EM/intensive carehttp://ekgumem.tumblr.com/ ECG video tutorialshttp://emtutorials.com/
  • 46. Real time on-line resourceseMedicineUpToDateBlue BookStarship Paediatric Guidelines
  • 47. Teaching sessions / case discussionsMonday 8:15 X-ray meetingTuesday 9am Dept meeting / Case discussionsTuesday 1pm ED RMO teaching sessionsThursday 1pm RMO teaching sessions1st Tuesday of each month 5pm Journal Club
  • 48. Suggestions / corrections:chricres@gmail.com