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CRITICAL CONCEPTSLSU SCHOOL OF MEDICINE

SENIOR ROTATION 2011-12

http://www.medschool.lsuhsc.edu/emergency_medicine/critical_concepts_rotation.aspx

Twitter: @emednolaFB: LSU-EM @ NOLA

WELCOME TO CRITICAL CONCEPTSROTATION OBJECTIVES: Provide all senior students with exposure

to acute and critical care concepts in a variety of learning modalities. 

Review and reinforce diagnostic and management skills in common and/or critical disease entities and procedures encountered in a range of specialties.

Prepare senior students for their new roles as resident physicians with direct patient care and health care team responsibilities.

UNDERLYING PRINCIPLE

Every physician – regardless of specialty – should know how to manage acutely ill, undifferentiated patients with a variety of emergent conditions

CLINICAL SCENARIOS

JUNE 5, 2012 / JULY 1, 2012

When suddenly …

“Is there a doctor on the plane?/in the ward?” your

picturehere

A 63 year old woman traveling alone in first class/admitted to the floor began shouting incoherently and wandering around about ten minutes ago. Suddenly, she slumps forward and becomes unresponsive.

The flight attendant/nurse hands you a medical bag. You are able to feel a weak radial pulse at approximately 110 beats/minute and note a respiratory rate of 8 breaths/minute.

WHAT NOW??

What would your immediate actions beIn the air?If/when this happens to you on your

first day of internship?

LIST 5 OF THE FOLLOWING:Initial actionsPossible diagnosesManagement/treatment steps

MANAGEMENT OF THE ACUTELY ILL PATIENT Based on the principles of

identifying and treating the immediate, life-threatening conditions first

All other considerations come second

KEEP IT SIMPLE

PRIMARY SURVEY

VITAL SIGNS = CRITICAL IMPORTANCE

HRRRBPTempPulse Ox

PRIMARY SURVEY

A – airway evaluationAre there any signs of obstruction?○ FB○ Masses○ Trauma○ TONGUE

INTERVENTIONS

RELIEVE THE OBSTRUCTION before moving on○ Finger sweep○ Chin tilt/head lift or jaw thrust○ Repositioning○ Suctioning/hemorrhage control

FUTURE AIRWAY PROTECTION?

PRIMARY SURVEY

B – breathing, oxygenation & ventilationIs the patient able to sufficiently

oxygenate and/or ventilate?Look for○ Agitation/restlessness○ Tachypnea/use of accessory muscles○ Bradypnea/apnea○ Breath sounds on BOTH sides○ Tracheal deviation?○ JVD?

PRIMARY SURVEY

Life threatening conditions requiring immediate interventionTension PTXFlail chestRespiratory failure/distress○ Primary pulmonary issue○ Consequence of underlying disorder

INTERVENTION: Assisted oxygenation/ventilation

through○ Supplemental O2 (how much & how?)○ Proper bag-valve-mask○ Non-invasive positive pressure

ventilation○ Intubation (RSI)

PRIMARY SURVEY

C – circulatory statusAssess for PULSES (bilaterally) and

heart tonesAny obvious bleeding?Other s/s:○ MS changes○ Cool, pale extremities○ Capillary refill○ BP/HR – shock index

PRIMARY SURVEY

Life threatening conditions requiring immediate interventionShock states:○ Hypovolemic?○ Cardiogenic?○ Distributive?○ Obstructive?

Active hemorrhage

INTERVENTION

Venous access (large bore/CVC) Administration of blood or fluid

products in rapid boluses Target to specific types of shock:

Cardiogenic – inotropes, BP support, procedures

Sepsis (distributive) – EGDT, source control

Obstructive (PE/tamponade) Anaphylactic – epi, antihistamines

PRIMARY SURVEY

D – disability assessmentMental status/level of consciousnessGross neurologic examPupilsGCS if trauma

INTERVENTION

Prompt imaging as warranted (trauma – hemorrhage or fracture; medical – CVA/mass)

Prompt Neuro specialist involvement if appropriate

Reversal/supportive care if toxidrome

Consider likelihood of airway protection (“GCS less than 8 = intubate”)

PRIMARY SURVEY

E – FULL exposureEvery inch of the patient is surveyed

and documented for obvious life threats

Occult traumatic injuryInfectious sourcesRashes/skin changesMedications/patches

INTERVENTIONS

Imaging/tests/treatment based on findings

Removal of any offending agent

After stabilization …

Brief, targeted HPI/PMH etc. (“AMPLE”)

REASSESSMENT OF VITAL SIGNS and success of any intervention

Detailed testing Longer-term treatment and

management Secondary survey: FULL PHYSICAL!

GOALS

… in the care of the undifferentiated patient:Identify life-threatening processesImmediate stabilizationConsideration of most serious and

most likely diagnosesInitiation of definitive treatment and

careUtilization of all available resources

when appropriate

DON’T BE AFRAID …

This is fun!

ROTATION HOUSEKEEPING

Course structure and expectations;1 didactics week2 EM weeks1 ICU week

You are expected to be an active participant in all parts of the course, and a full member of each team (consider yourselves acting interns)

YOUR GOALS

What should you get out of this?Expanded skills and knowledge base

from 3rd yearApplication of those skills/knowledge

to more complicated/critically ill patients

Increased exposure to/experience with common and emergent procedures & interventions

More sophisticated understanding of disease complexity & health systems management

Most of you are here:

We want to move you here:

REPORTER

INTERPRETERMANAGER

WHOWHAT

WHEREWHEN

HOWWHY

WHAT NEXT?

DIDACTICS WEEK Please read assigned material on

website prior to each session … come prepared to discuss!

Each of the 8 specialties has designed their own interactive module on what they perceive to be most important in managing their most critical or common emergencies

Each module requires a faculty/preceptor signature

ICU ROTATION

You are an active part of the ICU team and expected to have direct patient care and documentation duties

You should participate in family and team discussions of care plans

Details will differ between ICUs Information on where/when to

report to ICUs – see CC website under “Didactics Schedule & ICU Information”

EM ROTATION

Again, you are expected to have direct patient care responsibilities as part of the EM team

Please read the assigned EM readings during your 2 week block

While on the EM portion of the rotation, you are expected to attend EM student lectures and labs

SOCIAL MEDIA

Another part of the curriculum! Information available on the

website – there are several ways to have this information “pushed” to you

This content is testable!

CASE & PROCEDURE LOGS During your EM block, please log all

patient encounters and procedures that you observe, assist with, and/or perform into E*Value

If you have forgotten your logon/password … please let Dr. Avegno know

This is a way to begin to build your medical portfolio

RESPONSIBILITIES

BE ON TIME … for all sessions, rounds, and shifts

Adhere to the school honesty policy at all times

Be properly supervised in all educational and clinical settings and duties

EVALUATION METHODS

Final grade is based on:End of rotation on-line exam, derived

from:○ EM and specialty-specific reading (all online

on website)○ Social media content○ Didactic session lectures and labs

Professionalism assessment during clinical rotation

H/HP/P/F system Either component can be remediated

if necessary

ATTENDANCE POLICY

Students may miss 2 days of the rotation FOR INTERVIEWS ONLY:During EM block – may miss 1 ED shift

and one “free”dayDuring ICU block – if 2 ICU days are

missed, they must be remediated the weekend before or after (in order to have a full week of ICU)

DIDACTICS DAYS MAY NOT BE MISSED Please contact Dr. English or Dr.

Avegno for attendance questions

FORMS

Please turn in evaluation form to Jennifer Jeansonne, course coordinator, upon completion of the rotation (room 615)

NOW … ENJOY THE COURSE!