3. Bad asthma
Salbutamol - back to back nebs – oxygen driven
Ipratropium neb
Steroid eg prednisone
IV salbutamol
BiPAP eg 10/2cmH2O (continue nebs via BiPAP)
Rarely ketamine – senior doc
Nebulised adrenaline
IV magnesium is probably out for adults (but life threatening
asthma was excluded from the trial), probably works for kids
http://stemlynsblog.org/2013/05/jc-does-magnesium-work-in-
asthma-st-emlyns/
8. Wheezy babies
< 3 months consider congential heart disease
< 1 year = bronchiolitis
> 1 year = wheezy bronchitis, or if recurrent =
asthma
Any age: consider foreign body - but very rare
9. Wheezy babies
Rinse nose with saline
Oxygen in sats < 92%
< 6 months: don't use ß agonist or steroids
< 1 year: if family Hx of atopy try ß agonist
6 puffs via spacer q20 min.
If no objective improvement stop using
No steroids
> 1 year and working very hard or hypoxic
ß agonist and steroids
12. CCF
GTN 1-2 puffs SL PRN q5min if BP will tolerate
BiPAP or CPAP eg 10/5
? Frusemide if fluid overloaded
GTN patch or infusion if required
Can't do infusions on ward :-(
Early use of ACEI
13.
14. The highest rib space that can be easily felt in
the axilla.
Spontaneous: long needles eg central line
needle, 16 G angiocath
Trauma: finger thoracostomy: big cut with a
scalpel, then a finger in the hole to ensure you
are in the space.
17. “Moderate” pneumothorax can be aspirated eg
via long IV cannula but …Most often we are
putting in a 14Fr chest drain using Seldinger
technique
Video:
http://www.cookmedical.com/cc/datasheetMedia.
do?mediaId=4490&id=5392
Major trauma we will usually put in a 32Fr chest
tube by open technique - but this will change
over time - to smaller Seldinger drains.
We have 32Fr Seldinger sets.
18. If you have time - lots of long acting local
anaesthetic into the chest wall and pleural space
+ IV analgesia / procedural anaesthesia
20. All ECGs read by doctor as soon as they are
taken
Written interpretation
Time
Legible name
We will go through some key ECGs in the ECG
session and the syncope session
26. Tox ECG
Specific things to look at on the ECG of a patient
with a potential overdose.
These are covered in the tox talks Eg
http://emtutorials.com/2013/05/toxicology-for-
pgy12/
27.
28.
29. Shock
No single sign or test
Hypotension
Increased capillary refill time
Shut down peripheries
Raised lactate
Tachypnoea
Tachycardia
Decreased urine output (get a catheter in early)
(+/- IVC filling and cardiac contractility by u/s)
31. Shock
NZ is a civilised country and so very little
penetrating trauma
32. Shock
Use all your clinical skills to work out what is
going on
Consider a wide range of causes.
All hypotension in trauma is not hypovolaemia
Pneumothorax
Tamponade
Neurogenic shock (diagnosis of exclusion)
Use ultrasound: pneumothorax, blood around
heart, blood in abdo
34. Haemorrhagic shock
Use blood products early
Minimise use of crystaloid / colloid
O-negative blood available in minutes
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
36. IV Access
If you have failed to get an IV line in a patient
after 2 goes be nice to yourself and the patient
and get someone else to try.
We all have off days.
Remember the interosseous needle for adults or
kids
