We are very lucky to get ambo call about most serious cases
The 5 Ps of Preparation People Place Protection Plant Plan
People Get extra hands first – rate limiting step Get some extra help in – if in doubt ask the nurses ED consultant Anaesthetist/reg Surgical registrar XRay CT Lab Extra nurses Assign roles eg team leader, airway doc/nurse, examining doc, lines + procedures doc/nurse
Place Create a space for them Move people out of resus Move people out of ED
Personal Protective Equipment XRay gown Goggles Masks Lead apron Apron/gown Gloves
Plant = equipment and drugs Prepare ultrasound machine, blood, drugs eg analgesics, airway equipment etc as required based on the information you have
Plan Talk through your plan based on what you know with the team As you think out loud others can chip in with things you may not have thought of Gets everyone on the same page But remember the plan may change rapidly
ABCDEfG Can be applied to 95% of what we see in ED Use it for your approach and your documentation
Jaw thrust - mainly we do this one Chin lift Head tilt
Basic airway adjuncts What are they? What size do you use?
OPA = Guedel o Size from corner of mouth to angle of jaw o Insert upside down in adult, then rotate o Insert right way up in kids o If the patient tolerates an OPA that’s a fairly good indication they aren’t protecting their airway and probably need to be intubated o Image http://www.aic.cuhk.edu.hk/web8/0190_Guedel_airway_sizing.jpghttp://www.aic.cuhk.edu.hk/web8/0190_Guedel_airway_sizing.jpg
NPA o From nostril to tragus LMA o Weight written on packet. o 5: adult male o 4: adult female
Bag-Valve-Mask o Essential skill o Mask fits over bridge of nose and below lower lip but not under chin o Little finger behind ramus of mandible to lift jaw forward o 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_0 0000026_100000_large.jpg
Anaesthetic drugs Only with a Senior Medical Officer at the bedside. (But our system allows heroic doses of narcotics and benzodiazepines – which are probably more dangerous. Just don't send someone to Xray with a big dose of opioids on board)
ETT 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
Stridor Bad stridor - what are you going to do?
Stridor 5mg nebulised adrenaline / epinephrine = 5ml ampules of 1:1,000 (unless 0.5ml/kg of 1,000) Steroid eg dexamethasone 0.6mg/kg (max 12mg) PO, IM, IV
Anaphylaxis Bad anaphylaxis What are you going to do?
Anaphylaxis Mild cases may respond to just nebulised adrenaline, IV fluids, steroids BUT if in doubt: 0.5mg IM adrenaline + the above + steroids eg dexamethasone as for stridor +/- IV adrenaline eg 5-20mcg (eg 1mg in 1L Normal saline = 1mcg/ml) q 5min or push dose pressors http://emcrit.org/podcasts/bolus- dose-pressors/http://emcrit.org/podcasts/bolus- dose-pressors/ +/- Antihistamines
Can't ventilate Surgical cricothyroidotomy or needle cric in kids Surgical: scalpel - bougie – ETT– http://www.emrap.tv/index.php?option=com_content&view=article&id=2274 :EMRAPTV94-Cric-Bougie 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/emsthttp://www.surgeons.org/for-health-professionals/register-courses- events/skills-training-courses/emst/ http://www.airwayskills.co.nz/page.php?3
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. Ultrasound: pneumothorax, blood around heart, blood in abdo
Haemorrhagic shock Early use of blood products O neg available immediately 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
Haemorrhagic shock Trauma o Heamorrhage on the bed, in chest, abdo, pelvis, long bone o Clinical exam + ultrasound + XRay +/- CT External haemorrhage -> tourniquet or pressure Pelvis or long bone - stabilise with binder or splint Chest -> surgeon Abdo -> surgeon but often conservative Mx
Non haemorrhagic shock Treat specific cause If not sure: 500ml - 1L of saline likely to help
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