Part one of a crash course in emergency medicine for new ED docs

1. Crash Course in Emergency Medicine
For new ED docs
Key emergency procedures
Preparation
ABCs

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

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

7.  People
 Place
 Protection
 Plant
 Plan

8.  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

11.  Create a space for them
 Move people out of resus
 Move people out of ED

12.  Lead apron
 Apron/gown
 Goggles
 Mask
 Gloves

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

14.  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

15.  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

17.  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”

20.  What are they?

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

22.  What are they?
 How do we size them?

23.  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_airwa
y_sizing.jpg

24.  NPA
 From nostril to tragus
 LMA
 Weight written on packet.
 Adult male: 5
 Adult female: 4

25.  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_001
0_00000026_100000_large.jpg

26.  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)

27.  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

28.  Bad stridor - what are you going to do?

29.  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

30.  What are you going to do?

31.  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

32.  All of your airway maneuvers have failed
 What are you going to do?

33.  Adults: surgical cricothyroidotomy
 Kids: needle cricothyroidotomy

35.  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

36.  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

37.  Patient with angioedema of tongue
 What are you going to do?

38.  Nebulised adrenaline as above
 Usually ends up on a medium dose adrenaline
infusion eg 12mcg/minute