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Airway Management Emergency Medicine  Seminar Series
Michael Ha Section of Emergency Medicine  4th year Resident John Sokal Health Sciences Centre 12 years Bob Sweetland Health Sciences Centre 15 years
April 25, 2002 CHURCHILL ASHERN PINE FALLS
April 26, 2002 STEINBACH BOUNDARY  TRAILS
May 2, 2002 BRANDON KILLARNEY PORTAGE
May 3, 2002 RUSSELL DAUPHIN SWAN RIVER
May 14, 2002 FLIN FLON LYNN LAKE THE PAS
eMEDiUM Emergency Medicine  in the U of M emergency.mb.ca Back
CAEP  ACEP
CME Objectives To discuss: ,[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Master Preoxygenation Pretreatment O 2  Delivery Thiopental   Ketamine Propofol Succinylcholine Rocuronium Finish
Intubation Indications ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Back
HR 125  BP 98/40  RR 20  GCS 8  O 2 Sats 100% (PRB) no injuries Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases ,[object Object],[object Object],[object Object]
Cases ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],40	fire 22 	TCA 54	CRF 67	HTN 51	melena 45  overdose
60 male  IHD ,[object Object],[object Object],HR  110   BP  68 / 40  RR  10 O 2 Sats 90% (BVM)  Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases
44 female  ,[object Object],[object Object],HR  130  BP  100 / 70  RR  28 O 2 Sats 99% (BVM) GCS 6 Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases
25 female  asthma ,[object Object],[object Object],HR  145   BP  98 / 42  RR  30 O 2 Sats 80% (PRB) Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases
15  female   ,[object Object],HR  110  BP  100 / 50  RR  20 O 2 Sats 99% (BVM) GCS 8 Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases
28 male  ,[object Object],[object Object],HR 130  BP 80 / 60  RR 28 O 2 Sats 99% (PRB) abdomen rigid pelvic fracture Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases
16 male   ,[object Object],[object Object],HR 80  BP 115 / 60  RR 16 O 2 Sats 99% (room) voice change hematoma visible Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases
40 female  ,[object Object],[object Object],HR 115  BP 130 / 60  RR 28 O 2 Sats 96% (PRB) singed facial hair soot in mouth Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases
22  female   ,[object Object],[object Object],HR 145  BP 100 / 42  RR 14 O 2 Sats 99% (PRB) GCS 8 Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases
54 male  CRF  DM ,[object Object],[object Object],HR 115  BP 200 / 120  RR 36 O 2 Sats 88% (NRB) peaked T's Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases
67 female  HTN ,[object Object],[object Object],HR 85  BP 150 / 80  RR 20 O 2 Sats 99% (room) slight stridor Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases
51 male  cirrhosis   ,[object Object],[object Object],HR  165  BP  50 palpation  RR  28 O 2 Sats 92% (NRB) vomiting red blood Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases
68 male  CHF HR 125  BP 180 / 100  RR 32 O 2 Sats 86% (NRB) ,[object Object],[object Object],Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases
Intubate? Custom Shows
Intubate? HR 125  BP 98/40  RR 20  GCS 8  O 2 Sats 100% (PRB) no injuries Indication? ,[object Object],[object Object],[object Object]
Intubation Indications ,[object Object],[object Object]
Intubate? HR 135  BP 150/90  RR 10 O 2 Sats 86% (NRB)  'tight'  wheezes bilaterally Indication? ,[object Object],[object Object],[object Object]
Intubation Indications ,[object Object],[object Object]
Intubate? HR 100  BP 105/60  RR 20  GCS 10 O 2 Sats 100% (PRB)  multiple injuries transfering to HSC  Indication? ,[object Object],[object Object],[object Object]
Intubation Indications ,[object Object],[object Object]
Intubation Indications ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Back
RSI vs Awake? Custom Shows
Rapid Sequence Intubation a potent  induction agent   followed immediately by   ,[object Object],[object Object],a rapidly-acting  NMB   to induce unconsciousness and  motor paralysis for intubation.
Rapid Sequence Intubation ,[object Object],[object Object],[object Object],[object Object],[object Object]
The  7  P’s ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Awake Intubations ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Choices… paralyze? Paralysis contraindications ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Preparation Difficult   Airways Custom Shows
Preparation STOP IC BARS S staff, suction T tube O oxygen P pharmacology  (meds)
Preparation I intravenous lines C connect to monitors B blades, bougies A alternate  (lightwand)  R rescue  (LMA, combitube) S surgical  (cricothyroidotomy) STOP IC BARS Back
Difficult Mask Ventilation B  eard
Difficult Mask Ventilation O  bese
Difficult Mask Ventilation O  lder T  oothless
Difficult Mask Ventilation S  nores
Preparation Assessment for  Difficult Mask Ventilation BOOTS   B beard O obese O older T toothless S snores Back
Difficult Mask Ventilation reposition OP / NP airway 2 person  change mask ? obstruction Back
Repositioning Oral – Pharyngeal -  Laryngeal Axes
Repositioning Head extended on neck
Repositioning “ Sniffing” position
Repositioning “ Sniffing” with extension Back
Preparation Assessment for a difficult intubation Lemon Law   L look  E evaluate (3-3-1 rule) M Mallampati O obstruction N neck mobility Back
3-3-1 Rule Back 3 3 fingers mouth opening 1 finger anterior jaw  subluxation 3 1 3 fingers hyomental distance (room for tongue)
Mallampati Back
Preparation Preoxygenation Pretreatment
Preoxygenation is the establishment of an  oxygen reservoir. ,[object Object],[object Object],[object Object],[object Object]
Apnea Time Back
Pretreatment is the administration of drugs  to mitigate the adverse effects  associated with intubation. L  idocaine O  piodes A  tropine D  efasciculation Back
Induction Agents
Paralysis after induction thiopental ketamine propofol etomidate versed succinylcholine rocuronium skip drug section
Thiopental ,[object Object],[object Object],[object Object],Contraindication: porphyria INDUCTION
Thiopental Back INDUCTION Onset: 15 - 30   seconds Dose: 3 -  5   mg / kg (euvolemic) 1 -  3   mg / kg  (hypovolemic) Duration: 5 - 10   minutes
Ketamine ,[object Object],[object Object],[object Object],hypovolemic - hypotensive    agent of choice INDUCTION ,[object Object],[object Object],[object Object],[object Object]
Ketamine lower dose if profound shock: maximal sympathetic stimulation already - ketamine has intrinsic CV depression Back INDUCTION Onset: 15 - 30   seconds Dose: 1 -  2   mg / kg Duration: 15 - 30   minutes
Propofol ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],INDUCTION ,[object Object],ICP CPP
Propofol Onset: 30 - 40   seconds   1 -  3   mg / kg  (induction) Dose: Duration: 5 - 10   minutes Combo:  ketamine  50 mg propofol  50 mg Back Contraindication: egg, soybean allergies INDUCTION
Etomidate ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],INDUCTION ,[object Object],ICP
Etomidate Back Onset: 20 - 30   seconds Dose: 0.2 - 0.3   mg / kg INDUCTION Duration: 5 - 15   minutes
NMB
Choices… paralyze? Paralysis contraindications ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Choices… SUX or ROC? SUX contraindications ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Succinylcholine ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],PARALYSIS ,[object Object]
Succinylcholine Onset: 10 - 15   seconds  (fasciculations) 45 - 60  seconds (paralysis) Dose: 1  -  2   mg / kg  (adults)   2   mg / kg  (children) 3   mg / kg  (newborns) Duration: 3 -  5   minutes  (some resps) 8 - 10   minutes  (adequate) PARALYSIS
Succinylcholine Side- Effects ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Back PARALYSIS
Succinylcholine Fasciculations ,[object Object],[object Object],side-effects ,[object Object],PARALYSIS
Succinylcholine SUX-induced Hyperkalemia ,[object Object],[object Object],[object Object],[object Object],[object Object],Preexistent  K +  PARALYSIS
Succinylcholine ,[object Object],[object Object],[object Object],[object Object],Exaggerated release of K + PARALYSIS
Succinylcholine Exaggerated release of K + ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],side-effects PARALYSIS
Succinylcholine PARALYSIS Receptor Recruitment & Sensitization Onset: 7   days Duration: 2 - 3   months Crush: Onset: 7   days Duration: 6   months Denervation: Onset: 24   hours Duration: 2   years Burns: (% burn does not determine response)
Succinylcholine Neuromuscular disorders: SUX contraindicated side-effects PARALYSIS Receptor Recruitment & Sensitization ,[object Object],[object Object],[object Object]
Succinylcholine Bradycardia ,[object Object],[object Object],[object Object],[object Object],side-effects ,[object Object],PARALYSIS
Succinylcholine Prolonged Neuromuscular Blockade ,[object Object],[object Object],[object Object],[object Object],PARALYSIS
Succinylcholine ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Prolonged Neuromuscular Blockade PARALYSIS
Succinylcholine ,[object Object],[object Object],[object Object],[object Object],Prolonged Neuromuscular Blockade side-effects PARALYSIS
Succinylcholine ,[object Object],[object Object],Malignant Hyperthermia ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],PARALYSIS
Succinylcholine ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Malignant Hyperthermia side-effects PARALYSIS
Succinylcholine ,[object Object],Dantrolene  for MH ,[object Object],[object Object],[object Object],side-effects Dose: ,[object Object],[object Object],PARALYSIS
Succinylcholine Trismus - Masseter Muscle Spasm ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],side-effects PARALYSIS
Rocuronium ,[object Object],[object Object],[object Object],[object Object],[object Object],PARALYSIS
Rocuronium Dose: 0.6 - 1.2   mg / kg PARALYSIS Onset: 60 - 90   seconds Duration: 30 - 60   minutes Defasiculating: 0.05   mg / kg
Comparing NMB SUX ROC PARALYSIS ONSET 30 - 60 60 - 90  sec DURATION 3 - 10 20 - 60 min rapid rapid no priming CVS stability advantages precautions K +
Comparing NMB PARALYSIS sec min VEC 150 - 180 25 -  30 no histamine release PAN 120 - 180 60 -  90 histamine release ATRA 120 - 150 20 -  35 histamine release
Positioning Proof
Positioning with protection You are asked to apply: cricoid pressure (Sellick’s maneuver)
BURP B  ackwards U  pwards R  ightward P  ressure ,[object Object],[object Object],[object Object]
Maneuvers Back
Laryngoscopy
Laryngoscopy
Laryngoscopy
Laryngoscopy
Laryngoscopy
Placement with proof methods of confirmation chest rise air entry fogging of ETT 60 cc syringe * capnometer
Colorimetric Capnometry exhaled CO2   simple color change    from purple   to  yellow
Colorimetric Capnometry NEGATIVE POSITIVE
Colorimetric Capnometry ETCO 2  < 4  mm Hg ETT  not in  trachea inadequate perfusion (ineffective CPR)
Colorimetric Capnometry ETCO 2  15 - 38  mm Hg ETT  in  trachea
Colorimetric Capnometry ETCO 2  4 to < 15  mm Hg retained CO 2  in esophagus low perfusion deliver  6  more breaths
Colorimetric Capnometry Standard of Care Limitations: Back ,[object Object],[object Object],[object Object]
Bougie Lightwand LMA
Bougie
Epiglottis
Laryngoscopy Grades Cormack Lehane
Bougie
Lightwand
Lightwand Source: Laerdal
Lightwand Source: Laerdal
Laryngeal Mask Airway Source: LMA North America skip insertion technique
Laryngeal Mask Airway Source: LMA North America ,[object Object],[object Object],[object Object],skip insertion technique
Laryngeal Mask Airway Source: LMA North America ,[object Object],skip insertion technique
Laryngeal Mask Airway Source: LMA North America ,[object Object],[object Object],skip insertion technique
Laryngeal Mask Airway Source: LMA North America ,[object Object],[object Object],skip insertion technique
7. Postintubation mgmt fix tube in place CXR nasogastric  / orogastric tube lab  etc Back
O2 Delivery Systems
O 2  Delivery Systems ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
O 2  Delivery Systems ,[object Object],[object Object],[object Object],[object Object],[object Object]
O 2  Delivery Systems ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
O 2  Delivery Systems ,[object Object],[object Object],[object Object],[object Object],[object Object]
O 2  Delivery Systems ,[object Object],[object Object],[object Object]
Summary
Airway Management ? ?
eMEDiUM Emergency Medicine  in the U of M emergency.mb.ca Back
HSC ED  ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Back
CAEP  ACEP

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Skippen chong dong crrt-vn
 
Internet tiep can mach mau crrt-vn
Internet   tiep can mach mau crrt-vnInternet   tiep can mach mau crrt-vn
Internet tiep can mach mau crrt-vn
 
Internet mang loc va dich loc crrt-vn
Internet   mang loc va dich loc crrt-vnInternet   mang loc va dich loc crrt-vn
Internet mang loc va dich loc crrt-vn
 
Internet dieu tri thay the than crrt-vn
Internet   dieu tri thay the than crrt-vnInternet   dieu tri thay the than crrt-vn
Internet dieu tri thay the than crrt-vn
 
Internet cac phuong thuc dieu tri thay the than crrt-vn
Internet   cac phuong thuc dieu tri thay the than crrt-vnInternet   cac phuong thuc dieu tri thay the than crrt-vn
Internet cac phuong thuc dieu tri thay the than crrt-vn
 
Goldstein crrt tre em - chi dinh - crrt-vn
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Gambro dieu tri thay the than lien tuc crrt-vn
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07 capnography trends in procedural sedation
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20 patient monitoring
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19 introduction of volumetric capnography
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18 basics of pediatric airway anatomy, physiology and management
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17 capnography part4 non-intubated
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16 capnography part3 intubated
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15 capnography part2 introduction
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14 capnography part1 overview
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13 icu monitoring standards and capnography
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12 mainstream sidestream capnpgraphy
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Airway Management 3

Editor's Notes

  1. EM rotation is an opportunity to refine approach. Learning is by discussion &amp; review around cases seen while in ED. “ hit &amp; miss” - may not seen many critically ill patients / resuscitations. The purpose of this seminar is to review the basic aspects of critically ill patient assessment &amp; management and to allow you to practice these skills with simulated cases. Afterwards, hopefully you will feel more comfortable and confident when such patients require your attention on this rotation and subsequently.
  2. EM rotation is an opportunity to refine approach. Learning is by discussion &amp; review around cases seen while in ED. “ hit &amp; miss” - may not seen many critically ill patients / resuscitations. The purpose of this seminar is to review the basic aspects of critically ill patient assessment &amp; management and to allow you to practice these skills with simulated cases. Afterwards, hopefully you will feel more comfortable and confident when such patients require your attention on this rotation and subsequently.
  3. EM rotation is an opportunity to refine approach. Learning is by discussion &amp; review around cases seen while in ED. “ hit &amp; miss” - may not seen many critically ill patients / resuscitations. The purpose of this seminar is to review the basic aspects of critically ill patient assessment &amp; management and to allow you to practice these skills with simulated cases. Afterwards, hopefully you will feel more comfortable and confident when such patients require your attention on this rotation and subsequently.
  4. EM rotation is an opportunity to refine approach. Learning is by discussion &amp; review around cases seen while in ED. “ hit &amp; miss” - may not seen many critically ill patients / resuscitations. The purpose of this seminar is to review the basic aspects of critically ill patient assessment &amp; management and to allow you to practice these skills with simulated cases. Afterwards, hopefully you will feel more comfortable and confident when such patients require your attention on this rotation and subsequently.
  5. EM rotation is an opportunity to refine approach. Learning is by discussion &amp; review around cases seen while in ED. “ hit &amp; miss” - may not seen many critically ill patients / resuscitations. The purpose of this seminar is to review the basic aspects of critically ill patient assessment &amp; management and to allow you to practice these skills with simulated cases. Afterwards, hopefully you will feel more comfortable and confident when such patients require your attention on this rotation and subsequently.
  6. EM rotation is an opportunity to refine approach. Learning is by discussion &amp; review around cases seen while in ED. “ hit &amp; miss” - may not seen many critically ill patients / resuscitations. The purpose of this seminar is to review the basic aspects of critically ill patient assessment &amp; management and to allow you to practice these skills with simulated cases. Afterwards, hopefully you will feel more comfortable and confident when such patients require your attention on this rotation and subsequently.
  7. EM rotation is an opportunity to refine approach. Learning is by discussion &amp; review around cases seen while in ED. “ hit &amp; miss” - may not seen many critically ill patients / resuscitations. The purpose of this seminar is to review the basic aspects of critically ill patient assessment &amp; management and to allow you to practice these skills with simulated cases. Afterwards, hopefully you will feel more comfortable and confident when such patients require your attention on this rotation and subsequently.
  8. EM rotation is an opportunity to refine approach. Learning is by discussion &amp; review around cases seen while in ED. “ hit &amp; miss” - may not seen many critically ill patients / resuscitations. The purpose of this seminar is to review the basic aspects of critically ill patient assessment &amp; management and to allow you to practice these skills with simulated cases. Afterwards, hopefully you will feel more comfortable and confident when such patients require your attention on this rotation and subsequently.
  9. EM rotation is an opportunity to refine approach. Learning is by discussion &amp; review around cases seen while in ED. “ hit &amp; miss” - may not seen many critically ill patients / resuscitations. The purpose of this seminar is to review the basic aspects of critically ill patient assessment &amp; management and to allow you to practice these skills with simulated cases. Afterwards, hopefully you will feel more comfortable and confident when such patients require your attention on this rotation and subsequently.
  10. Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  11. Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  12. Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  13. Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  14. Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  15. Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  16. Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  17. Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  18. Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  19. Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  20. Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  21. Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  22. Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  23. Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  24. Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  25. Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  26. Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  27. Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  28. Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  29. 332 rule – geometry of oral intubation chin/mentum – hyhoid - thyroid Is the mandible large enough to accommodate tongue? (3-4 cm or 3 fingers) a very long mandible elongates the oral axis Length of neck – position of larynx
  30. 332 rule – geometry of oral intubation chin/mentum – hyhoid - thyroid Is the mandible large enough to accommodate tongue? (3-4 cm or 3 fingers) a very long mandible elongates the oral axis Length of neck – position of larynx
  31. 332 rule – geometry of oral intubation chin/mentum – hyhoid - thyroid Is the mandible large enough to accommodate tongue? (3-4 cm or 3 fingers) a very long mandible elongates the oral axis Length of neck – position of larynx
  32. 332 rule – geometry of oral intubation chin/mentum – hyhoid - thyroid Is the mandible large enough to accommodate tongue? (3-4 cm or 3 fingers) a very long mandible elongates the oral axis Length of neck – position of larynx
  33. 332 rule – geometry of oral intubation chin/mentum – hyhoid - thyroid Is the mandible large enough to accommodate tongue? (3-4 cm or 3 fingers) a very long mandible elongates the oral axis Length of neck – position of larynx
  34. 332 rule – geometry of oral intubation chin/mentum – hyhoid - thyroid Is the mandible large enough to accommodate tongue? (3-4 cm or 3 fingers) a very long mandible elongates the oral axis Length of neck – position of larynx
  35. 332 rule – geometry of oral intubation chin/mentum – hyhoid - thyroid Is the mandible large enough to accommodate tongue? (3-4 cm or 3 fingers) a very long mandible elongates the oral axis Length of neck – position of larynx
  36. Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  37. Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  38. Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  39. DRUG SUPPLIED: COST Metabolism SUX 20 mg/ml 20 ml $ 0.88 plasma pseudocholinesterase ROC 10 mg/ml 5 ml $ 12.75 hepatic - major renal - 33% unchanged VEC 10 mg vial $ 16.03 hepatobiliary - 50% renal 30% PAN 2 mg/ml 5 ml $ 2.58 renal - unchanged (major) 2 mg/ml 2 ml $ 1.10 biliary - 2% 1 mg/ml 5 ml $ 2.74 ATRA 10 mg vial $ 7.85 Hoffman elimination hydrolysis - nonspecific enzymatic
  40. Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  41. Demonstration &amp; explanation of equipment and technique
  42. Demonstration &amp; explanation of equipment and technique
  43. Demonstration &amp; explanation of equipment and technique
  44. Demonstration &amp; explanation of equipment and technique
  45. Demonstration &amp; explanation of equipment and technique
  46. Demonstration &amp; explanation of equipment and technique
  47. Demonstration &amp; explanation of equipment and technique
  48. Accuracy: older generation oximeters – corresponded to oxyhemoglobin dissociation curve – 1-2% on flat portion, 5-6% on steep portion (&lt;90%) More recent generation – above Newer generation – 1-2% across oxyhemoglobin dissociation curve All are kept well calibrated by our RT’s.
  49. Accuracy: older generation oximeters – corresponded to oxyhemoglobin dissociation curve – 1-2% on flat portion, 5-6% on steep portion (&lt;90%) More recent generation – above Newer generation – 1-2% across oxyhemoglobin dissociation curve All are kept well calibrated by our RT’s.
  50. Accuracy: older generation oximeters – corresponded to oxyhemoglobin dissociation curve – 1-2% on flat portion, 5-6% on steep portion (&lt;90%) More recent generation – above Newer generation – 1-2% across oxyhemoglobin dissociation curve All are kept well calibrated by our RT’s.
  51. Accuracy: older generation oximeters – corresponded to oxyhemoglobin dissociation curve – 1-2% on flat portion, 5-6% on steep portion (&lt;90%) More recent generation – above Newer generation – 1-2% across oxyhemoglobin dissociation curve All are kept well calibrated by our RT’s.
  52. Accuracy: older generation oximeters – corresponded to oxyhemoglobin dissociation curve – 1-2% on flat portion, 5-6% on steep portion (&lt;90%) More recent generation – above Newer generation – 1-2% across oxyhemoglobin dissociation curve All are kept well calibrated by our RT’s.
  53. Accuracy: older generation oximeters – corresponded to oxyhemoglobin dissociation curve – 1-2% on flat portion, 5-6% on steep portion (&lt;90%) More recent generation – above Newer generation – 1-2% across oxyhemoglobin dissociation curve All are kept well calibrated by our RT’s.
  54. Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  55. Demonstration &amp; explanation of equipment and technique
  56. Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  57. Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  58. EM rotation is an opportunity to refine approach. Learning is by discussion &amp; review around cases seen while in ED. “ hit &amp; miss” - may not seen many critically ill patients / resuscitations. The purpose of this seminar is to review the basic aspects of critically ill patient assessment &amp; management and to allow you to practice these skills with simulated cases. Afterwards, hopefully you will feel more comfortable and confident when such patients require your attention on this rotation and subsequently.
  59. EM rotation is an opportunity to refine approach. Learning is by discussion &amp; review around cases seen while in ED. “ hit &amp; miss” - may not seen many critically ill patients / resuscitations. The purpose of this seminar is to review the basic aspects of critically ill patient assessment &amp; management and to allow you to practice these skills with simulated cases. Afterwards, hopefully you will feel more comfortable and confident when such patients require your attention on this rotation and subsequently.
  60. EM rotation is an opportunity to refine approach. Learning is by discussion &amp; review around cases seen while in ED. “ hit &amp; miss” - may not seen many critically ill patients / resuscitations. The purpose of this seminar is to review the basic aspects of critically ill patient assessment &amp; management and to allow you to practice these skills with simulated cases. Afterwards, hopefully you will feel more comfortable and confident when such patients require your attention on this rotation and subsequently.