Download - ED Orientation Part 2: B and C
ED Orientation Part 2
Breathing + Circulation
Asthma
Bad asthma
What are you going to do?
Bad asthmaSalbutamol - back to back nebs – oxygen driven
Ipratropium neb
Steroid eg prednisone
IV salbutamol
BiPAP eg 10/2cmH2O (continue nebs via BiPAP)
Rarely ketamine – senior doc
Nebulised adrenaline
IV magnesium is probably out for adults (but life threatening asthma was excluded from the trial), probably works for kids http://stemlynsblog.org/2013/05/jc-does-magnesium-work-in-asthma-st-emlyns/
CXR +/- or U/S to rule out pneumothorax
COPD
Bad COPD What are you going to do?
COPD
Work out ceiling of care
Nebuliser
BiPAP eg 10/5.
Continue neb via BiPAP
Steroids
Antibiotics if productive cough
Wheezy babies
Working hard to breath
What are you going to do?
Wheezy babies
< 3 months consider congential heart disease
< 1 year = bronchiolitis
> 1 year = wheezy bronchitis, or if recurrent = asthma
Any age: consider foreign body - but very rare
Wheezy babies
Rinse nose with saline
Oxygen in sats < 92%
< 6 months: don't use ß agonist or steroids
< 1 year: if family Hx of atopy try ß agonist6 puffs via spacer q20 min. If no objective improvement stop usingNo steroids
> 1 year and working very hard or hypoxicß agonist and steroids
Wheezy babies
Admit if
RR > 60
Unable to feed
Sats < 92% on RA
Poor social situation
CCF
Bad CCF
What are you going to do?
CCF
GTN 1-2 puffs SL PRN q5min if BP will tolerate
BiPAP or CPAP eg 10/5
? Frusemide if fluid overloaded
GTN patch or infusion if requiredCan't do infusions on ward :-(
Early use of ACEI
The highest rib space that can be easily felt in the axilla.
• Spontaneous: long needles eg central line needle, 16 G angiocath
• Trauma: finger thoracostomy: big cut with a scalpel, then a finger in the hole to ensure you are in the space.
• http://lifeinthefastlane.com/2011/04/own-the-chest-tube/
• “Moderate” pneumothorax can be aspirated eg via long IV cannula but …Most often we are putting in a 14Fr chest drain using Seldinger technique
• Video: http://www.cookmedical.com/cc/datasheetMedia.do?mediaId=4490&id=5392
• Major trauma we will usually put in a 32Fr chest tube by open technique - but this will change over time - to smaller Seldinger drains. – We have 32Fr Seldinger sets.
• If you have time - lots of long acting local anaesthetic into the chest wall and pleural space
• + IV analgesia / procedural anaesthesia
C
• All ECGs read by doctor as soon as they are taken
• Written interpretation
• Time
• Legible name
• We will go through some key ECGs in the ECG session and the syncope session
STEMI
• Thrombolyse in ED
• Streptokinase or Tenectoplase
• Follow the ACS pathway
Syncope or new seizure ECG
• See http://emtutorials.com/2013/05/syncope-beardsell-semep/
Temporary treatment for hypotension
Push dose pressors
• Phenylephrine: pure alpha = vasoconstrictor without tachycardia
• 10mg of phenylephrine in 100ml normal saline = 100µg/ml
• 2ml = 200µg works in a few minutes, lasts about 5 minutes
Push dose pressors
• Adrenaline/epinephrine
• Vasoconstriction + increased cardiac contractility
• Risk of tachyarrythmia
• 1 ml of 1:10,000 (100mcg) made up to 10ml with normal saline = 10mcg/ml 0.5-2ml push
Tox ECG
• Specific things to look at on the ECG of a patient with a potential overdose.
• These are covered in the tox talks Eg http://emtutorials.com/2013/05/toxicology-for-pgy12/
Shock• No single sign or test
• Hypotension
• Increased capillary refill time
• Shut down peripheries
• Raised lactate
• Tachypnoea
• Tachycardia
• Decreased urine output (get a catheter in early)
• (+/- IVC filling and cardiac contractility by u/s)
Types of Shock?
• Volume loss – eg haemorrhage, 3rd spacing
• Obstruction – eg PE, tamponade
• Pump failure – eg MI, CCB overdose, sepsis, valve pathology
• Vasodilation – eg sepsis, overdose, anaphylaxis, neurogenic
Shock
• NZ is a civilised country and so very little penetrating trauma
Shock
• Use all your clinical skills to work out what is going on
• Consider a wide range of causes.
• All hypotension in trauma is not hypovolaemia– Pneumothorax– Tamponade– Neurogenic shock (diagnosis of exclusion)
• Use ultrasound: pneumothorax, blood around heart, blood in abdo
Haemorrhagic shock
• Trauma – Haemorrhage
• on the bed, • in chest, • abdo, • pelvis, • long bone
– Tension pneumothorax, tamponade– Clinical exam + ultrasound + XRay +/- CT
Haemorrhagic shock
• Use blood products early
• Minimise use of crystaloid / colloid
• O-negative blood available in minutes
• FFP takes half an hour to thaw - request early
• Platelets come by taxi from 1 hour away
• Use tranexamic acid 1g IV over 10 minutes then 1g IV over 8 hours
Non haemorrhagic shock
• Treat specific cause
• If not sure: 500ml - 1L of saline likely to help
IV Access
• If you have failed to get an IV line in a patient after 2 goes be nice to yourself and the patient and get someone else to try.– We all have off days.
• Remember the interosseous needle for adults or kids
http://www.vidacare.com/admin/files/T427RevC-Insert-RemPoster.pdf