ED Orientation Part 1: Prep and Airway


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Part one of a crash course in emergency medicine for new ED docs

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ED Orientation Part 1: Prep and Airway

  1. 1. Crash Course in Emergency MedicineFor new ED docsKey emergency proceduresPreparationABCs
  2. 2.  Not comprehensive Just the things you reallyneed to know / will scare the crap out ofyou
  3. 3.  If you are thinking “Should I discuss this witha senior?” ...
  4. 4.  People Place Protection Plant Plan
  5. 5.  Get extra hands first – rate limiting step ED consultant Anaesthetist/reg Surgical registrar Xray CT Lab Extra nurses/RMOs/ midwife if pregnantwoman / paeds nurse if it’s a very sick kid Assign roles eg team leader, airway doc/nurse,examining doc, lines + procedures doc/nurse
  6. 6.  Create a space for them Move people out of resus Move people out of ED
  7. 7.  Lead apron Apron/gown Goggles Mask Gloves
  8. 8.  Ultrasound Drugs Age / size appropriate airway equipment Drug calculations if paediatric Resuscitaire for babies
  9. 9.  Talk through your plan Think out loud so others can suggest thingsyou have forgotten + everyone on same page BUT remember to be flexible with the plan
  10. 10.  Can be applied to 95% of what we see in ED Use it for your approach and yourdocumentation Systematic But if enough people can simultaneously doA+ B + C + D etc
  11. 11.  Spinal precautions initially for any moderate- major trauma. Stabilise c-spine with collar Grip head and shoulders when moving/logroll Controlled slide on sliding board Person at head directs movements “Roll,2,3” -> roll on “3”
  12. 12.  What are they?
  13. 13.  Log roll / recovery position Jaw thrust - mainly we do this one Chin lift Head tilt
  14. 14.  What are they? How do we size them?
  15. 15.  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 goodindication they aren’t protecting their airway andprobably need to be intubated Imagehttp://www.aic.cuhk.edu.hk/web8/0190_Guedel_airway_sizing.jpg
  16. 16.  NPA From nostril to tragus LMA Weight written on packet. Adult male: 5 Adult female: 4
  17. 17.  Essential skill Mask fits over bridge ofnose and below lowerlip but not under chin Little finger behindramus of mandible tolift jaw forward Use a two hand grip onface and mask ifneeded – get someoneelse to squeeze the bagif neededImage:https://www.proceduresconsult.jp/UploadedImages/pcj_0010_00000026_100000_large.jpg
  18. 18.  Only with a Senior Medical Officer at thebedside. Low dose ketamine for analgesia acceptablefor RMO use eg 10-20mg in an adult (But our system allows heroic doses ofnarcotics and benzodiazepines – which areprobably more dangerous. Be careful! Don’t send anyone to Xray with a big dose ofopioids or benzos onboard)
  19. 19.  So for you guys flying solo, an ETT is only fordead people. LMA very acceptable (for anyone with no gagreflex If you are intubating we have a videolaryngoscope
  20. 20.  Bad stridor - what are you going to do?
  21. 21.  5mg nebulised adrenaline / epinephrine =5ml ampules of 1:1,000 (unless < 10kg ->0.5ml/kg of 1:1,000) Steroid eg dexamethasone 0.15mg/kg (max12mg)PO, IM, IV
  22. 22.  What are you going to do?
  23. 23.  Mild cases may respond to just nebulisedadrenaline, IV fluids, steroids BUT if in doubt: 0.5mg IM adrenaline + theabove If not responding quickly IV adrenaline eg 5-20mcg q5min eg 1ml of1:10,000 made up to 10ml with normal saline =10mcg/ml) http://emcrit.org/podcasts/bolus-dose-pressors/ +/- Antihistamines
  24. 24.  All of your airway maneuvers have failed What are you going to do?
  25. 25.  Adults: surgical cricothyroidotomy Kids: needle cricothyroidotomy
  26. 26.  16G iv cannula through cricothyroidmembrane. Wall Oxygen @ 1L/min/year of age. 1 second on, 1 second off. We have a home made jet insufflation kit inthe bottom draw of each airway trolley
  27. 27.  Airway study day twice a year in Whanganui:crics, chest drains etc on dead sheep. EMST or Auckland Airway Course to do sameon anaesthetised animals http://www.surgeons.org/for-health-professionals/register-courses-events/skills-training-courses/emst/http:// www.airwayskills.co.nz/page.php?3
  28. 28.  Patient with angioedema of tongue What are you going to do?
  29. 29.  Nebulised adrenaline as above Usually ends up on a medium dose adrenalineinfusion eg 12mcg/minute