critical care tips & tricks dr. matthew inwood. disclosures none
TRANSCRIPT
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CRITICAL CARE TIPS & TRICKS
Dr. Matthew Inwood
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Disclosures
None
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Objectives
Identify & discuss procedural techniques and therapeutic modalities to improve quality of care & patient safety when caring for the critically ill.
Identify & discuss therapeutic modalities to improve efficiency & optimise resource utilisation in the Emergency Department.
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Case #1
38 y.o male, found unresponsive at the bus station, with an empty oxycontin Rx container in his hand.
Pin-point pupils, SaO2 94%, GCS 11.
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Case #1
Re-assessed 60 minutes later… SaO2 90%, occasional desats & apneic
periods GCS 8 PCO2 95 & pH 7.10 on VBG
How do you treat this patient’s toxidrome?
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Case #1
IV naloxone can precipitate a life-threatening withdrawal reaction
IV access can be difficult
Needles convey a risk of exposure to blood bourne pathogens
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Case #1
Nebulised Naloxone!
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Case #1
Nebulised Naloxone, cont’d…
Weber et al, Pre-hospital Emergency Care 16: 2012
-105 patients
22%, complete response
59%, partial response
19%, no response
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Case #1
Nebulised Naloxone, cont’d…
How many doses are required?
Weber et al, 10% of patients required IV rescue dose
Baumann et al, 40% of patients required > 1 dose
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Case #1
Nebulised Naloxone, cont’d…
My Experience & Advice 2mg of naloxone & 3cc of normal saline
“Stimulate” patient to breathe
Allow patients to self titrate their medication
How much Naloxone do you have in your department?
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Case #2
28 year old male.
MVC. Ejected from vehicle at 120 km/h
Arrives intubated, doesn’t move extremities
HR 65, BP 89/60
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Case #2
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Case #2
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Case #2
Guide Wire J-Tip Orientation: Tripathi et al, Anesthesia & Analgesia 2005;
100: 21-4
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Case #2
Guide Wire J-Tip Orientation:
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Case #2
The “Ambesh” Maneuver: Manual occlusion of the ipsilateral Internal
Jugular vein at the supraclavicular fossa.
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Case #2
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Case #2
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Case #3
18 year old male, right sided thoracic stab wound.
Deviated trachea, shallow resps, absent right breath sounds.
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Case #3
Are you in the right place?
Ferrie et al, Emerg Med J 2005;22:788–789
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Case #3
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Case #3
Is your patient too thick or your needle too short?
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Case #3
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Case #3
Is your patient too thick or your needle too short? Zengerink et al 2008
Retrospective review of Chest CTs for blunt trauma
Measured distance from skin to pleura at 2nd ICS, MCL
Mean CWT = 3.51cm right, 3.5cm left
19% of men had CWT > 4.5cm
35.4% of women had CWT > 4.5cm
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Case #3
Is there a preferred alternate site of Needle Thoracostomy?
Inaba et al, 2011 Cadaver study. Needle thoracostomy at 2
different sites Does a lateral approach lead to more
successful placement?
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Case #3
2nd ICS MCL
5th ICS MAL
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Case #3
Is there a preferred alternate site of Needle Thoracostomy? Inaba et al, 2012
Step-wise increase in CWT across all BMI quartiles @ each location
CWT was less at 5th ICS
42.5% of patients had CWT >4.5CM @ MCL, & 16.7% @ 5th ICS
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Case #4
56 year old obese male, collapsed and seized at a shopping mall food court.
Arrives in your ED GCS 3, sonorous resps and vomiting
Despite your best efforts, this patient desats before you can pass the ET tube
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Case #4
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Case #4
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Case #4
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Case #4
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Case #4
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Case #4
High Flow Apneic Oxygenation How Does it Work? Complications?
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Case #4
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Questions?