ed orientation part 3: more on circuclation through to self care and study

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, hypotensionRecent onset AF ->Seek and treat any precipitant: sepsis, CCFSynchronised electrical cardioversion 200J

Tachycardias

Chronic AF, CP, hypotension

Tachycardias

Chronic 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

Tachycardias

Tachycardias

Sinus tachyP waves in V1Best way is to look at monitor - sinus tachy rate

varies. SVT does not.

Tachycardias

Tachycardias

SVTVagal manoeuvres: Ice, carotid sinus (if < 60),

Valsalva eg blow into 10ml syringeAdults: Calcium channel blocker eg Diltiazem 15-

20mg or verapamil 2.5mg Adenosine 12, 18, 18mg fast push

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 unit re insulin and glucose, HCO3, frusemide.

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

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 overloadedTranscutaneous pacing -> Transvenous

pacing. Isoprenaline infusion

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 seizure last 3 minutes what are you going to do?

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.

… 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

Coma

Causes?

Approach?

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!)

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.

Coma

Usually intubation by ED senior unless fairly sure just drunk or poor prognosis in elderly -> recovery position

CT brain

Reassess with results

Analgesia

Fentanyl for moderate - severe painLess itch, hypotension, nausea than morphine1µg/kg IV/IO, 1.5-3µg/kg IN, repeat PRN No diamorph in NZConvert to morphine (longer acting than

fentanyl) if needed when pain under control

Paracetamol load 20mg/kg then 15mg/kg thereafter

Ibuprofen 10mg/kg

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 toxicityIntralipid

Analgesia

Consider a PCA on the wardCharted by an emergency physician or

anaesthetist

Ketamine infusions eg 0.3mg/kg/hour titrated to pain / confusion

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

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

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

Gynae shock

If 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

If shocked + miscarrying in early pregnancy

Remove POC from CxMisoprostal 800mg PR or buccallyTranexamic acid 1g IV

If still bleeding ++ -> transfuse and call gynae + theatre (rare)

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

Have a lunch break

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 quicklyWrite a very brief note eg sudden onset

headache, CGS 15 P: analgesia, CT, review after CT ? for LP

Order the testsThen see the next patient

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.

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 …”

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

Pick the nurses brains

If you think you should ring a consultant / registrar -> ring 'em

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

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

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

Self care

Information overload

We can't know everything

We are human and make mistakes

Accept yourself and work to improve

Self care / being a better doc

Meditation

http://emtutorials.com/2013/04/mindfulness-for-health-professionals/

Sleephttp://emtutorials.com/2013/04/insomnia-and-

sleep/

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/

Real time on-line resources

eMedicine

UpToDate

Blue Book

Starship Paediatric Guidelines

Links on the RMO page on the intranet

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

Suggestions / corrections:

chricres@gmail.com

Credits: most ECGs from Amal Mattu