CRITICAL CONCEPTSLSU SCHOOL OF MEDICINE

SENIOR ROTATION 2012-13

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

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: Case 1

JUNE 5, 2013

When suddenly …“Is there a doctor on the plane?

yourpicturehere

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

The flight attendant 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.

CLINICAL SCENARIOS: Case 2

JULY 1, 2013

When suddenly … your pager goes off …

A 60 year old man admitted to the floor got up to go to the restroom. Suddenly, he fell back into bed and became unresponsive.

The floor nurse goes out to find a code cart. You are able to feel a weak radial pulse at approximately 120 beats/minute and note a respiratory rate of 10 breaths/minute.

CLINICAL SCENARIOS: Case 3

October 10, 2013

You are on your EM rotation on a busy night shift when …

EMS brings in a 57 year old man who was an unrestrained driver in a rollover MVC with multiple cars. He was not responsive at the scene.

Vital signs in the ambulance were HR 115, BP 100/60, and RR 10. All of the EM residents are busy working up the other cars’ passengers.

WHAT NOW?? What would your immediate actions be

In the air?If/when this happens to you on your first day of

internship? If you are the first medical professional caring for

an acutely ill/injured patient?

FOR EACH CASE - 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 SURVEYVITAL SIGNS = CRITICAL IMPORTANCE

HRRRBPTempPulse Ox

PRIMARY SURVEYA – airway evaluation

Are 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 status

Assess for PULSES (bilaterally) and heart tones

Any 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 assessment

Mental 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 exposure

Every 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 year

Application 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”*

*TICU students – please contact fellows for time/place to meet prior to starting the week

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

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

patient encounters and procedures that you observe, assist with, and/or perform into New Innovations

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!