More ECGs
Tachycardias
Tachycardias 
WCT -> synchronised (if has a pulse) 
electrically cardiovert 200J 
(happens to be WPW AF)
Tachycardias
Tachycardias 
VF. 200J unsych. 2 minutes CPR, repeat. 
Adrenaline after 2 zaps, amiodarone next 
cycle etc
Tachycardias 
Recent onset palpitation, Chest pain.
Tachycardias 
Recent onset palpitation, CP, hypotension 
Recent onset AF -> 
Seek and treat any precipitant: sepsis, CCF 
...
Tachycardias 
Chronic AF, CP, hypotension
Tachycardias 
Chronic AF, CP 
Seek and treat precipitant eg CCF, sepsis, hypovolaemia 
Rate control eg diltiazem 10mg IV, ...
Tachycardias
Tachycardias 
Sinus tachy 
P waves in V1 
Best way is to look at monitor - sinus tachy rate varies. 
SVT does not.
Tachycardias
Tachycardias 
SVT 
Vagal manoeuvres: Ice, carotid sinus (if < 60), Valsalva eg 
blow into 10ml syringe 
Adults: Calcium ch...
Tachycardias 
40 renal patient with CP and SOB
Tachycardias 
Hyper K. 
What are you going to do? 
What's your threshold?
Hyper K with widened QRS 
Salbutamol 10mg neb 
Calcium gluconate 10mmol = 1 amp 
Urgent dialysis 
If delay to dialysis d/w...
Renal failure patients 
ECG on arrival – look for hyperK 
Fentanyl for analgesia rather than morphine or 
tramadol 
CAPD p...
Tachycardias
Tachycardias 
LBBB + sinus tachy
Compare with this
Bradycardia 
Hypotensive, pale, faint. 
What are you going to do?
Bradycardia 
CPR if needed (no pulse, losing consciousness) 
Fluid load if not overloaded 
Transcutaneous pacing -> Transv...
D 
Seizures 
You are called to a room where a febrile child 
has been seizing for 1 minute 
What are you going to do?
Seizures 
Reassure everybody 
Turn the child on his/her side 
Suction if necessary 
Oxygen 
Wait for seizure to stops 
If ...
Seizures 
Check blood sugar (2 ml/kg of 10% dextrose, 
recheck BSL after 15 minutes) 
Benzodiazepine 
We usually use midaz...
… still seizing … 
IV phenytoin 15mg/kg over 20 minutes 
Antibiotics eg ceftriaxone 100mg/kg to max of 2g 
Call paeds 
Wai...
Coma 
Causes? 
Approach?
Coma 
Go through ABCDEG including a glucose 
Then use eg AEIOUTIPS 
Alcohol and other drugs 
Electrolytes, encephalopathy ...
Coma 
In practice: 
Firm stimulus eg triceps pinch 
Physical exam including basic neuro 
Look for eg deviated eyes as sign...
Coma 
Usually intubation by ED senior unless fairly 
sure just drunk or poor prognosis in 
elderly -> recovery position 
C...
Analgesia 
Fentanyl for moderate - severe pain 
Less itch, hypotension, nausea than morphine 
1μg/kg IV/IO, 1.5-3μg/kg IN,...
Analgesia 
Ketamine eg 5-30mg as analgesic 
50% or 70% nitrous oxide 
Long acting local anaesthetics (eg bupivocaine 
2.5m...
Analgesia 
Consider a PCA on the ward 
Charted by an emergency physician or anaesthetist 
Ketamine infusions eg 0.3mg/kg/h...
G: Glucose, Guts (abdo), Gynae 
Hypoglycaemia 
3-4 Oral glucose tabs then food 
If unable to eat: 2ml/kg 10% glucose +/- 
...
G 
Abdo pain in the elderly (> 50 male > 60 
female) 
Be afraid 
Low threshold for bedside u/s for AAA 
Low threshold for ...
Gynae 
ßHCG in almost every female of childbearing 
age who is in ED 
Shock in early pregnancy = ectopic till proven 
othe...
Gynae shock 
If unable to do bedside ultrasound 
-> PV exam - remove POC from cervix 
If no products is internal os open? ...
If shocked + miscarrying in early pregnancy 
Remove POC from Cx 
Misoprostal 800mg PR or buccally 
Tranexamic acid 1g IV 
...
POC 
Many women from many cultures want to 
keep/bury products of conception - don't 
just throw POC is the rubbish.
Managing your day
Managing your day 
Don't take too many patients at once 
To start with don't have more than 3 active patients 
Take breaks...
Managing your day 
As you get used to the job aim to take 3 
patients in the first 20 minutes of your shift. 
See them qui...
Managing your day 
Don't take on new patients in your last hour: tidy up your 
remaining patients, sign off some labs or X...
Treat the nurses with the 
respect they deserve 
Nurses out-rank you in our ED 
They have more experience than you 
They w...
Managing your night
Managing your night 
Have a nap 
If that little voice says don't send that patient 
home -> keep 'em, especially after 3am...
If you need senior help, and you are fairly sure 
which speciality the patient will be 
admitted under please call that re...
I expected to be called once a night on your 
first set of nights 
If in doubt ask a nurse 
If a nurse thinks you need hel...
Managing your night 
You will feel your performance improves over 
your set of nights 
It doesn't 
You get worse 
If in do...
Self care 
Information overload 
We can't know everything 
We are human and make mistakes 
Accept yourself and work to imp...
Self care / being a better doc 
Meditation 
http://emtutorials.com/2013/04/mindfulness-for-health- 
professionals/ 
Sleep ...
Study 
45 minutes then take a 15 minute break 
http://lifeinthefastlane.com/ Links to all free EM teaching 
http://embasic...
Real time on-line resources 
eMedicine 
UpToDate 
Blue Book 
Starship Paediatric Guidelines 
Links on the RMO page on the ...
Teaching sessions / case discussions 
Monday 8:15 X-ray meeting 
Tuesday 9am Dept meeting / Case discussions 
Tuesday 1pm ...
Suggestions / corrections: 
chricres@gmail.com 
Credits: most ECGs from Amal Mattu
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

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Orientation for new ED doctors

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  • What&amp;apos;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&amp;apos;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

    1. 1. More ECGs
    2. 2. Tachycardias
    3. 3. Tachycardias WCT -> synchronised (if has a pulse) electrically cardiovert 200J (happens to be WPW AF)
    4. 4. Tachycardias
    5. 5. Tachycardias VF. 200J unsych. 2 minutes CPR, repeat. Adrenaline after 2 zaps, amiodarone next cycle etc
    6. 6. Tachycardias Recent onset palpitation, Chest pain.
    7. 7. Tachycardias Recent onset palpitation, CP, hypotension Recent onset AF -> Seek and treat any precipitant: sepsis, CCF Synchronised electrical cardioversion 200J
    8. 8. Tachycardias Chronic AF, CP, hypotension
    9. 9. Tachycardias Chronic AF, CP Seek and treat precipitant eg CCF, sepsis, hypovolaemia Rate control eg diltiazem 10mg IV, 20mg 15 min later if needed ½ dose if hypotensive. May need diltiazem + phenylephrine Check BP before each dose
    10. 10. Tachycardias
    11. 11. Tachycardias Sinus tachy P waves in V1 Best way is to look at monitor - sinus tachy rate varies. SVT does not.
    12. 12. Tachycardias
    13. 13. Tachycardias SVT Vagal manoeuvres: Ice, carotid sinus (if < 60), Valsalva eg blow into 10ml syringe Adults: Calcium channel blocker eg Diltiazem 15-20mg or verapamil 2.5mg Adenosine 12, 18, 18mg fast push
    14. 14. Tachycardias 40 renal patient with CP and SOB
    15. 15. Tachycardias Hyper K. What are you going to do? What's your threshold?
    16. 16. Hyper K with widened QRS Salbutamol 10mg neb Calcium gluconate 10mmol = 1 amp Urgent dialysis If delay to dialysis d/w renal unit re insulin and glucose, HCO3, frusemide.
    17. 17. Renal failure patients ECG on arrival – look for hyperK Fentanyl for analgesia rather than morphine or tramadol CAPD patients with belly pain or any signs of sepsis -> eyeball the dialysate -> cloudy = peritonitis -> intraperitoneal Abs +/- Sepsis Pathway
    18. 18. Tachycardias
    19. 19. Tachycardias LBBB + sinus tachy
    20. 20. Compare with this
    21. 21. Bradycardia Hypotensive, pale, faint. What are you going to do?
    22. 22. Bradycardia CPR if needed (no pulse, losing consciousness) Fluid load if not overloaded Transcutaneous pacing -> Transvenous pacing. Isoprenaline infusion
    23. 23. D Seizures You are called to a room where a febrile child has been seizing for 1 minute What are you going to do?
    24. 24. Seizures Reassure everybody Turn the child on his/her side Suction if necessary Oxygen Wait for seizure to stops If seizure last 3 minutes what are you going to do?
    25. 25. Seizures Check blood sugar (2 ml/kg of 10% dextrose, recheck BSL after 15 minutes) Benzodiazepine We usually use midazolam 0.15mg/kg IV or 0.2mg/kg IM. Can also use IN, buccal, rectal. Repeat if still seizing after 5 minutes.
    26. 26. … still seizing … IV phenytoin 15mg/kg over 20 minutes Antibiotics eg ceftriaxone 100mg/kg to max of 2g Call paeds Wait The brain won’t fry from a prolonged seizure Usually better to wait for the seizure to stop than to intubate – especially in our context where we don’t have 24/7 medical cover in critical care
    27. 27. Coma Causes? Approach?
    28. 28. Coma Go through ABCDEG including a glucose Then use eg AEIOUTIPS Alcohol and other drugs Electrolytes, encephalopathy (hepatic, hypercapnic, hypertensive (NB kids), infective, endocrine) Inborn errors, intestinal disaster Overdose Uraemia Trauma, toxins Infection Psychiatric Seizure (including non-convulsive and post ictal), Stroke, SOL, snake or spider bite (not in NZ!)
    29. 29. Coma In practice: Firm stimulus eg triceps pinch Physical exam including basic neuro Look for eg deviated eyes as sign of non-convulsive status Blood sugar ECG Urine Labs including a venous gas, LFT.
    30. 30. Coma Usually intubation by ED senior unless fairly sure just drunk or poor prognosis in elderly -> recovery position CT brain Reassess with results
    31. 31. Analgesia Fentanyl for moderate - severe pain Less itch, hypotension, nausea than morphine 1μg/kg IV/IO, 1.5-3μg/kg IN, repeat PRN No diamorph in NZ Convert to morphine (longer acting than fentanyl) if needed when pain under control Paracetamol load 20mg/kg then 15mg/kg thereafter Ibuprofen 10mg/kg
    32. 32. Analgesia Ketamine eg 5-30mg as analgesic 50% or 70% nitrous oxide Long acting local anaesthetics (eg bupivocaine 2.5mg/kg) – wrists, ribs, clavicles, wrist blocks, ring blocks, femoral nerve, fascia iliaca/triple block. Local anaesthetic toxicity Intralipid
    33. 33. Analgesia Consider a PCA on the ward Charted by an emergency physician or anaesthetist Ketamine infusions eg 0.3mg/kg/hour titrated to pain / confusion
    34. 34. G: Glucose, Guts (abdo), Gynae Hypoglycaemia 3-4 Oral glucose tabs then food If unable to eat: 2ml/kg 10% glucose +/- infusion if still unable to eat
    35. 35. G Abdo pain in the elderly (> 50 male > 60 female) Be afraid Low threshold for bedside u/s for AAA Low threshold for CT abdo
    36. 36. Gynae ßHCG in almost every female of childbearing age who is in ED Shock in early pregnancy = ectopic till proven otherwise. Bedside ultrasound for free fluid in abdo. If +ve call gynae, transfuse, tranexamic acid
    37. 37. Gynae shock If unable to do bedside ultrasound -> PV exam - remove POC from cervix If no products is internal os open? Yes -> miscarriage – see next slide No -> call gynae +/- urgent ultrasound
    38. 38. If shocked + miscarrying in early pregnancy Remove POC from Cx Misoprostal 800mg PR or buccally Tranexamic acid 1g IV If still bleeding ++ -> transfuse and call gynae + theatre (rare)
    39. 39. POC Many women from many cultures want to keep/bury products of conception - don't just throw POC is the rubbish.
    40. 40. Managing your day
    41. 41. Managing your day Don't take too many patients at once To start with don't have more than 3 active patients Take breaks Have a lunch break
    42. 42. Managing your day As you get used to the job aim to take 3 patients in the first 20 minutes of your shift. See them quickly Write a very brief note eg sudden onset headache, CGS 15 P: analgesia, CT, review after CT ? for LP Order the tests Then see the next patient
    43. 43. Managing your day Don't take on new patients in your last hour: tidy up your remaining patients, sign off some labs or XRays and check work emails. Handover any remaining patients before you go Trust that your colleagues will be taking good care of your patients and let them go.
    44. 44. Treat the nurses with the respect they deserve Nurses out-rank you in our ED They have more experience than you They will protect their patients … and therefore you They will give you great advice and may help with lines and bloods if they have time Listen to them Ask for help When requesting they do a job say “Please would you …” not “Could we please …”
    45. 45. Managing your night
    46. 46. Managing your night Have a nap If that little voice says don't send that patient home -> keep 'em, especially after 3am Pick the nurses brains If you think you should ring a consultant / registrar -> ring 'em
    47. 47. If you need senior help, and you are fairly sure which speciality the patient will be admitted under please call that registrar (ortho, surg) or consultant (other specialities) If you are not sure which speciality the patient comes under or you need ED specific skills call the ED consultant Better to overcall than undercall
    48. 48. I expected to be called once a night on your first set of nights If in doubt ask a nurse If a nurse thinks you need help s/he will call us
    49. 49. Managing your night You will feel your performance improves over your set of nights It doesn't You get worse If in doubt talk to the boss or keep the patient in
    50. 50. Self care Information overload We can't know everything We are human and make mistakes Accept yourself and work to improve
    51. 51. 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/
    52. 52. 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/
    53. 53. Real time on-line resources eMedicine UpToDate Blue Book Starship Paediatric Guidelines Links on the RMO page on the intranet
    54. 54. Teaching sessions / case discussions Monday 8:15 X-ray meeting Tuesday 9am Dept meeting / Case discussions Tuesday 1pm ED RMO teaching sessions Thursday 1pm RMO teaching sessions 1st Tuesday of each month 5pm Journal Club
    55. 55. Suggestions / corrections: chricres@gmail.com Credits: most ECGs from Amal Mattu

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