ed orientation part 3: more on circuclation through to self care and study
DESCRIPTION
Orientation for new ED doctorsTRANSCRIPT
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More ECGs
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Tachycardias
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Tachycardias
WCT -> synchronised (if has a pulse) electrically cardiovert 200J
(happens to be WPW AF)
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Tachycardias
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Tachycardias
VF. 200J unsych. 2 minutes CPR, repeat. Adrenaline after 2 zaps, amiodarone next cycle etc
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Tachycardias
Recent onset palpitation, Chest pain.
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Tachycardias
Recent onset palpitation, CP, hypotensionRecent onset AF ->Seek and treat any precipitant: sepsis, CCFSynchronised electrical cardioversion 200J
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Tachycardias
Chronic AF, CP, hypotension
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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
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Tachycardias
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Tachycardias
Sinus tachyP waves in V1Best way is to look at monitor - sinus tachy rate
varies. SVT does not.
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Tachycardias
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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
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Tachycardias
40 renal patient with CP and SOB
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Tachycardias
Hyper K. What are you going to do?What's your threshold?
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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.
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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
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Tachycardias
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Tachycardias
LBBB + sinus tachy
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Compare with this
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Bradycardia
Hypotensive, pale, faint. What are you going to do?
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Bradycardia
CPR if needed (no pulse, losing consciousness)
Fluid load if not overloadedTranscutaneous pacing -> Transvenous
pacing. Isoprenaline infusion
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D
Seizures
You are called to a room where a febrile child has been seizing for 1 minute
What are you going to do?
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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?
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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.
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… 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
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Coma
Causes?
Approach?
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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!)
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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.
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Coma
Usually intubation by ED senior unless fairly sure just drunk or poor prognosis in elderly -> recovery position
CT brain
Reassess with results
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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
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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
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Analgesia
Consider a PCA on the wardCharted by an emergency physician or
anaesthetist
Ketamine infusions eg 0.3mg/kg/hour titrated to pain / confusion
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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
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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
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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
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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
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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)
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POC
Many women from many cultures want to keep/bury products of conception - don't just throw POC is the rubbish.
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Managing your day
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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
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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
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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.
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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 …”
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Managing your night
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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
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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
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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
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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
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Self care
Information overload
We can't know everything
We are human and make mistakes
Accept yourself and work to improve
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Self care / being a better doc
Meditation
http://emtutorials.com/2013/04/mindfulness-for-health-professionals/
Sleephttp://emtutorials.com/2013/04/insomnia-and-
sleep/
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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/
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Real time on-line resources
eMedicine
UpToDate
Blue Book
Starship Paediatric Guidelines
Links on the RMO page on the intranet
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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