An introduction to the emergency department for new doctors
Citation preview
1. ED orientationCrash Course in Emergency MedicineFor junior
ED docsPreparationABCsMonday, 27 May 13
2. Not comprehensiveJust the things you really need to know /
will scare the crapout of youMonday, 27 May 13
3. Ask a nurseMonday, 27 May 13
4. If you are thinking Should I discuss this with asenior?
...Monday, 27 May 13
5. Monday, 27 May 13
6. We are very lucky to get ambo call about mostserious
casesMonday, 27 May 13
7. The 5 Ps of PreparationPeoplePlaceProtectionPlantPlanMonday,
27 May 13
8. PeopleGet extra hands first rate limiting stepGet some extra
help in if in doubt ask the nursesED
consultantAnaesthetist/regSurgical registrarXRayCTLabExtra
nursesAssign roles eg team leader, airway doc/nurse, examining
doc,lines + procedures doc/nurseMonday, 27 May 13
9. Monday, 27 May 13
10. Monday, 27 May 13
11. PlaceCreate a space for themMove people out of resusMove
people out of EDMonday, 27 May 13
12. Personal Protective EquipmentXRay
gownGogglesMasksApron/gownGlovesMonday, 27 May 13
13. Plant = equipment and drugsPrepare ultrasound machine,
blood, drugs eganalgesics, airway equipment etc asrequired based on
the information you haveMonday, 27 May 13
14. PlanTalk through your plan based on what youknow with the
teamAs you think out loud others can chip in withthings you may not
have thought ofGets everyone on the same pageBut remember the plan
may change rapidlyMonday, 27 May 13
15. ABCDEfGCan be applied to 95% of what we see in EDUse it for
your approach and yourdocumentationMonday, 27 May 13
16. A + ?Monday, 27 May 13
17. Airway + c-spineSpinal precautions initially for any
moderate -major trauma.Stabilise c-spine with collarGrip head and
shoulders when movingControlled slide on sliding board OKMonday, 27
May 13
18. 2 best airway tools?Monday, 27 May 13
19. Monday, 27 May 13
20. Basic airway maneuversWhat are they?Monday, 27 May 13
21. Jaw thrust - mainly we do this oneChin liftHead tiltMonday,
27 May 13
22. Basic airway adjunctsWhat are they?What size do you
use?Monday, 27 May 13
23. OPA = Guedelo Size from corner of mouth to angle of jawo
Insert upside down in adult, then rotateo Insert right way up in
kidso If the patient tolerates an OPA thats a fairly good
indicationthey arent protecting their airway and probably need to
beintubatedo Image
http://www.aic.cuhk.edu.hk/web8/0190_Guedel_airway_sizing.jpgMonday,
27 May 13
24. NPAo From nostril to tragusLMAo Weight written on packet.o
5: adult maleo 4: adult femaleMonday, 27 May 13
25. Bag-Valve-Masko Essential skillo Mask fits over bridge
ofnose and below lower lipbut not under chino Little finger behind
ramusof mandible to lift jawforwardo Use a two hand grip onface and
mask if needed get someone else tosqueeze the bag ifneeded Image:
https://www.proceduresconsult.jp/UploadedImages/pcj_0010_00000026_100000_large.jpgMonday,
27 May 13
26. Anaesthetic drugsOnly with a Senior Medical Officer at
thebedside.(But our system allows heroic doses ofnarcotics and
benzodiazepines which areprobably more dangerous. Just dont
sendsomeone to Xray with a big dose of opioidson board)Monday, 27
May 13
27. ETTSo for you guys flying solo, an ETT is only fordead
people.LMA very acceptable (for anyone with no gagreflexIf you are
intubating we have a videolaryngoscopeMonday, 27 May 13
28. StridorBad stridor - what are you going to do?Monday, 27
May 13
29. Stridor5mg nebulised adrenaline / epinephrine = 5mlampules
of 1:1,000 (unless < 10kg -> 0.5ml/kg of 1:1,000)Steroideg
dexamethasone 0.6mg/kg (max 12mg)PO, IM, IVMonday, 27 May 13
30. AnaphylaxisBad anaphylaxisWhat are you going to do?Monday,
27 May 13
31. AnaphylaxisMild cases may respond to just nebulised
adrenaline, IV fluids,steroidsBUT if in doubt: 0.5mg IM adrenaline
+ the above+ steroids eg dexamethasone as for stridor+/- IV
adrenaline eg 5-20mcg q5min eg 1ml of 1:10,000 made up to10ml with
normal saline = 10mcg/ml)
http://emcrit.org/podcasts/bolus-dose-pressors/+/-
AntihistaminesMonday, 27 May 13
32. Cant ventilateWhat are you going to do?Monday, 27 May
13
33. Cant ventilateSurgical cricothyroidotomy or needle cric in
kidsSurgical: scalpel - bougie
ETThttp://www.emrap.tv/index.php?option=com_content&view=article&id=2274:EMRAPTV94-Cric-BougieNeedle
cric: eg 16G iv cannula through cricothyroid membrane. Wall Oxygen@
1L/min/year of age. 1 second on, 1 second off. We have a home
madejet insufflation kit in the bottom draw of each airway
trolleyAirway study day twice a year in Whanganui: crics, chest
drains etc on deadsheep.EMST or Auckland Airway Course to do same
on anaesthetised
animalshttp://www.surgeons.org/for-health-professionals/register-courses-events/skills-training-courses/emst/http://www.airwayskills.co.nz/page.php?3Monday,
27 May 13
34.
http://www.emrap.tv/index.php?option=com_content&view=article&id=2274:EMRAPTV94-Cric-BougieMonday,
27 May 13
35.
http://www.emrap.tv/index.php?option=com_content&view=article&id=2274:EMRAPTV94-Cric-BougieMonday,
27 May 13
36. Big tonguePatient with idiopathic tongue angioedemaWhat are
you going to do?Monday, 27 May 13
37. Big tongueNebulised adrenalineUsually ends up on a medium
dose adrenalineinfusion eg 12mcg/minuteMonday, 27 May 13