ed orientation part 1: prep and airway
DESCRIPTION
Part one of a crash course in emergency medicine for new ED docsTRANSCRIPT
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