An introduction to the emergency department for new doctors

1. ED orientation
Crash Course in Emergency Medicine
For junior ED docs
Preparation
ABCs
Monday, 27 May 13

2. Not comprehensive
Just the things you really need to know / will scare the crap
out of you
Monday, 27 May 13

3. Ask a nurse
Monday, 27 May 13

4. If you are thinking “Should I discuss this with a
senior?” ...
Monday, 27 May 13

5. Monday, 27 May 13

6. We are very lucky to get ambo call about most
serious cases
Monday, 27 May 13

7. The 5 Ps of Preparation
People
Place
Protection
Plant
Plan
Monday, 27 May 13

8. 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
Monday, 27 May 13

9. Monday, 27 May 13

10. Monday, 27 May 13

11. Place
Create a space for them
Move people out of resus
Move people out of ED
Monday, 27 May 13

12. Personal Protective Equipment
XRay gown
Goggles
Masks
Apron/gown
Gloves
Monday, 27 May 13

13. Plant = equipment and drugs
Prepare ultrasound machine, blood, drugs eg
analgesics, airway equipment etc as
required based on the information you have
Monday, 27 May 13

14. 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
Monday, 27 May 13

15. ABCDEfG
Can be applied to 95% of what we see in ED
Use it for your approach and your
documentation
Monday, 27 May 13

16. A + ?
Monday, 27 May 13

17. Airway + c-spine
Spinal precautions initially for any moderate -
major trauma.
Stabilise c-spine with collar
Grip head and shoulders when moving
Controlled slide on sliding board OK
Monday, 27 May 13

18. 2 best airway tools?
Monday, 27 May 13

19. Monday, 27 May 13

20. Basic airway maneuvers
What are they?
Monday, 27 May 13

21. Jaw thrust - mainly we do this one
Chin lift
Head tilt
Monday, 27 May 13

22. Basic airway adjuncts
What are they?
What size do you use?
Monday, 27 May 13

23. 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.jpg
Monday, 27 May 13

24. NPA
o From nostril to tragus
LMA
o Weight written on packet.
o 5: adult male
o 4: adult female
Monday, 27 May 13

25. 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_00000026_100000_large.jpg
Monday, 27 May 13

26. 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)
Monday, 27 May 13

27. 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
Monday, 27 May 13

28. Stridor
Bad stridor - what are you going to do?
Monday, 27 May 13

29. Stridor
5mg nebulised adrenaline / epinephrine = 5ml
ampules of 1:1,000 (unless < 10kg -> 0.5ml/
kg of 1:1,000)
Steroid
eg dexamethasone 0.6mg/kg (max 12mg)
PO, IM, IV
Monday, 27 May 13

30. Anaphylaxis
Bad anaphylaxis
What are you going to do?
Monday, 27 May 13

31. 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 q5min eg 1ml of 1:10,000 made up to
10ml with normal saline = 10mcg/ml) http://emcrit.org/
podcasts/bolus-dose-pressors/
+/- Antihistamines
Monday, 27 May 13

32. Can't ventilate
What are you going to do?
Monday, 27 May 13

33. 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
Needle cric: eg 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
Monday, 27 May 13

34. http://www.emrap.tv/index.php?
option=com_content&view=article&id=2274:EMRAPTV94-Cric-Bougie
Monday, 27 May 13

35. http://www.emrap.tv/index.php?
option=com_content&view=article&id=2274:EMRAPTV94-Cric-Bougie
Monday, 27 May 13

36. Big tongue
Patient with idiopathic tongue angioedema
What are you going to do?
Monday, 27 May 13

37. Big tongue
Nebulised adrenaline
Usually ends up on a medium dose adrenaline
infusion eg 12mcg/minute
Monday, 27 May 13

38. B
Monday, 27 May 13