ed orientation part 1: prep and airway

Crash Course in Emergency Medicine For new ED docs

Key emergency procedures

Preparation

ABCs

Not comprehensive Just the things you really need to know / will scare the crap out of you

If you are thinking “Should I discuss this with a senior?” ...

People Place Protection Plant Plan

Get extra hands first – rate limiting step ED consultant Anaesthetist/reg Surgical registrar Xray CT Lab Extra nurses/RMOs/ midwife if pregnant

woman / paeds nurse if it’s a very sick kid Assign roles eg team leader, airway

doc/nurse, examining doc, lines + procedures doc/nurse

Create a space for them Move people out of resus Move people out of ED

Lead apron Apron/gown Goggles Mask Gloves

Ultrasound Drugs Age / size appropriate airway equipment Drug calculations if paediatric Resuscitaire for babies

Talk through your plan Think out loud so others can suggest

things you have forgotten + everyone on same page

BUT remember to be flexible with the plan

Can be applied to 95% of what we see in ED

Use it for your approach and your documentation

Systematic

But if enough people can simultaneously do A+ B + C + D etc

Spinal precautions initially for any moderate - major trauma.

Stabilise c-spine with collar Grip head and shoulders when

moving/log roll Controlled slide on sliding board Person at head directs movements “Roll,2,3” -> roll on “3”

What are they?

Log roll / recovery position Jaw thrust - mainly we do this one Chin lift Head tilt

What are they?

How do we size them?

Size from corner of mouth to angle of jaw

Insert upside down in adult, then rotate Insert right way up in kids If the patient tolerates an OPA that’s a fairly

good indication they aren’t protecting their airway and probably need to be intubated Image

http://www.aic.cuhk.edu.hk/web8/0190_Guedel_airway_sizing.jpg

NPAFrom nostril to tragus

LMAWeight written on packet. Adult male: 5Adult female: 4

Essential skill Mask fits over bridge

of nose and below lower lip but not under chin

Little finger behind ramus of mandible to lift jaw forward

Use a two hand grip on face and mask if needed – get someone else to squeeze the bag if needed

Image: https://www.proceduresconsult.jp/UploadedImages/pcj_0010_00000026_100000_large.jpg

Only with a Senior Medical Officer at the bedside.

Low dose ketamine for analgesia acceptable for RMO use eg 10-20mg in an adult

(But our system allows heroic doses of narcotics and benzodiazepines – which are probably more dangerous.

Be careful! Don’t send anyone to Xray with a big

dose of opioids or benzos onboard)

So for you guys flying solo, an ETT is only for dead people.

LMA very acceptable (for anyone with no gag reflex

If you are intubating we have a video laryngoscope

Bad stridor - what are you going to do?

5mg nebulised adrenaline / epinephrine = 5ml ampules of 1:1,000 (unless < 10kg -> 0.5ml/kg of 1:1,000)

Steroid eg dexamethasone 0.15mg/kg (max 12mg)PO, IM, IV

What are you going to do?

Mild cases may respond to just nebulised adrenaline, IV fluids, steroids

BUT if in doubt: 0.5mg IM adrenaline + the above

If not responding quickly IV adrenaline eg 5-20mcg q5min eg 1ml of

1:10,000 made up to 10ml with normal saline = 10mcg/ml) http://emcrit.org/podcasts/bolus-dose-pressors/

+/- Antihistamines

All of your airway maneuvers have failed

What are you going to do?

Adults: surgical cricothyroidotomy Kids: needle cricothyroidotomy

16G iv cannula through cricothyroid membrane.

Wall Oxygen @ 1L/min/year of age. 1 second on, 1 second off. We have a home made jet insufflation

kit in the bottom draw of each airway trolley

Airway study day twice a year in Whanganui: cric's, chest drains etc on dead sheep.

EMST or Auckland Airway Course to do same on anaesthetised animals

http://www.surgeons.org/for-health-professionals/register-courses-events/skills-training-courses/emst/http://

www.airwayskills.co.nz/page.php?3

Patient with angioedema of tongue

What are you going to do?

Nebulised adrenaline as above

Usually ends up on a medium dose adrenaline infusion eg 12mcg/minute