Author: Karen Winter

Terence’s Guide to Appiness

 

mdcalc

https://www.mdcalc.com/

 

clinicians health channel – guidelines, eTG, MIMS

https://www2.health.vic.gov.au/clinicianshealthchannel

 

trauma victoria

https://trauma.reach.vic.gov.au/

 

uptodate – via western health library access

 

Austin Health Toxicology

http://www.austin.org.au/page?ID=1779

app also available

 

IC@N – Intensive Care at the Northern

– from appstore

 

APLS – app for algorithms

 

Visible Body – Anatomy Atlas (app)

 

References on Tap – quick literature search

 

Paediatric Emergencies – dose and tube size calculations

 

EM logbook – log procedures but remember to export to another source to save

 

Vic Emergency app – good for camping and travelling! Local warnings

 

 

walking through the central line

we discovered at registrar training last week that many of our team had not placed a central line so here is a walk through the process….

PREPARATION

 

Patient:

Why does the patient need CVC – access, multiple lumens, centrally active medications, monitoring

Where should the CVC go – IJ, subclavian, femoral

Position – complications to lying flat, Trendelenburg, sedation/intubated

Potential complications – bleeding, pneumothorax, failure

Consent the patient – procedure, options, complications (pain, allergic reaction, bleeding, pneumothorax, infection, failure, neuropraxia)

 

Equipment:

Set it up yourself

US – cover, sterile gel, positioning

Procedure tray – large area

Dishes – antiseptic wash, saline, disposing sharps

CVC kit – introducer/seeker, guidewire (check glides, some unwrap but care doesn’t become unsterile), dilator, CVC – check each lumen/leave brown uncapped, caps, adjustable hubs)

Syringes – 5ml for local, 20ml for saline + needles

Gauze

Gown, gloves, mask, goggles, drapes

Suture material and instruments

Local anaesthetic

Antiseptic skin wash

Clear dressing to fix line

 

Department:

Team – performing clinician, assistant, supervising doctor, backup

Monitoring of patient – ECG (BP + Sats if sedated)

Timing

Nurse in charge aware

 

PROCEDURE

Check vein with US first – position, anatomy, thrombus

Position patient/US/procedure tray/staff to monitor

Scrub hands, glove + gown

Wash patient + drape – large sterile area

Draw up LA

Position equipment in order of use so easy to reach

Check CVC lumens with saline flush + leave brown lumen uncapped

US to identify vein

50mg lignocaine with adrenaline into skin

Seeker needle with saline in syringe, using US in longitudinal to guide and cannulate vein

Hold with other hand to fix position on skin

Remove syringe

Feed guidewire, remove needle

Confirm position of wire with US before dilating

Dilate vein

Feed CVC with one hand always holding guidewire (care that wire does not become unsterile), depth determined by line markings 10-15cm – confirm ECG trace

Remove wire – announce to staff to document

Aspirate and flush each lumen before capping

Fix to skin with hub (clamp and fastener)

Suture 4 points (hub and distal) position

Cover with clear dressing

Confirm position with CXR

Dispose of sharps/wire and biohazard material

DOCUMENTATION:

Aseptic technique

Location

Local anaesthetic

Vein cannulated – number of attempts

Guide wire inserted, vein dilated, CVC inserted, GUIDE WIRE REMOVED, fixed at “x”cm

Complications

Confirmed with CXR – position in SVC at junction with RA (level of right main bronchus), no pneumothorax

 

For more information about MENTAL REHEARSAL and how this can help in critical situations and performing procedures, read this link:

EMCrit-RACC / EHPR Part 5: Using Mental Practice and Visualization Exercises by Mike Lauria

 

ANZAC DAY – self directed learning

ANZAC Day commemorates all Australians and New Zealanders “who served and died in all wars, conflicts, and peacekeeping operations” and “the contribution and suffering of all those who have served”.

Although I personally find it difficult to celebrate the outcomes of war, acts of aggression are a part of our lives and we, as Emergency Physicians, need to be prepared to treat individual victims as well as prepare our departments in case of a disaster.  Additionally, many of you have been, or will be, invovled in working in conflict areas.  Please take a moment during the public holiday to reflect on the victims as well as the strength and courage of the many who protect the innocent, strive to create peace and treat the victims of aggression.

 

We have added some relevant educational links:

BURNS

Major burns are often transferred to the tertiary centres in Melbourne.

The issues to consider include:

  • Fluid Resuscitation – caution in fluid overload, reassessment and special patients at risk of pulmonary oedema
  • Airway management – early intubation in inhalation injuries associated with respiratory distress, elderly or COPD with minimal respiratory reserve or those requiring transfer to a tertiary centre

 

 

ANALGESIA IN TRAUMA

It is easy to forget to provide adequate and appropriate pain releif while focussing on the resuscitation of the patient and the management of severe injuries.

The key issues:

  • Adequate analgesia promotes healing, reduces post-traumatic stress response, improves morbidity and mortality and reduces length of stay
  • Appropriate assessment tool depending on age, cultural background and language
  • Reassessment of pain score
  • Use of multimodal analgesia and consider early PCA and nerve blocks

 

Pain Management in Trauma A review Study_Injury and Violence 2016

 

DISASTER PREPAREDNESS

Often asked in OSCEs, preparing for a disaster or mass casualty event is not just a hypothetical.

Key Issues:

  • Details of the event and special situations/injuries – ie: burns, exposure to cold, chemical injuries
  • Prepare your team, your department and your hospital
  • Post-disaster debreif and hospital recovery

 

Treating the Enemy – the ethics of war

Treating the Doctor

 

International Womens Day – March 8, 2018

Tomorrow (March 8) is International Women’s Day.

 

Please take a moment to consider gender equality for your colleagues, your patients and your community.

https://acem.org.au/News/March-2018/A-time-for-recognition-and-thanks.aspx

 

 

https://www.internationalwomensday.com/

 

Some of the issues we encounter every day:

  • Effects of drugs and treatments specific to women – side effects, pharmacokinetics
  • Patient privacy – during conversations, examinations and procedures
  • Domestic Violence
  • Communication with other staff members

 

 

Winter’s Wrap 29.11.2017

CAUDA EQUINA SYNDROME

         

lower motor neurone compression….

  1. Urinary retention – flaccid bladder + detrusor
  2. Faecal incontinence – flaccid voluntary sphincter
  3. Flaccid paralysis of lower limbs
  4. Saddle anaesthesia (S1-S4)
  5. Bilateral loss of ankle jerk (S1)
  6. Compression of multiple nerve roots – bilateral sciatica is worse prognosis

May not have ALL signs

Monitor for gradual progression of symptoms – repeat examinations

Ask “When was the last time you walked?”

If >48 hours since onset of symptoms, unlikely to see much improvement after surgical intervention

 

Causes:

Disc herniation – young more common

Abscess – elderly, immunocompromised, IVDU

tumour – mets, lymphoma

 

Examination tips:

Flex hips – remove tension on iliopsoas when lying flat

Flex knees ot 45 degrees

Clear commands

Can’t fake collapsing weakness

sensation in dermatome distribution

Ankle jerk – cross ankle over opposite ankle with foot in cocked position

PR – key to S1-S4 sensation, also anal tone – check after relax then repeat tone

Winter’s Wrap 22.11.2017

VENTING YOUR FRUSTRATIONS – Dr Stacy Turner

Ventilation Handout Nov 17

Hamilton Ventilator Simulator: https://www.hamilton-medical.com/

take away points:

low pressure, low volume

optimise expiratory time if obstructive pathology

titrate FiO2 (88-95%), then adjust PEEP to FiO2

 

trouble shooting:

check compliance/resistance

MV depends on the patient – if awake patient has higher RR (eg: DKA, sepsis), need to raise RR to normalise pCO2 to awake patient compensation

set alarms to AUTO, check peak pressure set to “40”

“Deterioating patient” algorithm

 

 

TAKOTSUBO TRICKS – Dr Ross McNaught

Stress induced cardiomyopathy with normal coronary arteries – emotional stress, sepsis, respiratory failure

Usually completely recovers in weeks to months, may recur

Pathophysiology – catecholamine excess

Atypical features – no chest pain

ECG shows ST elevation, anterior leads

 

Echo – most common is left ventricular “ballooning” and apical hypokinesis

Consider concurrent LVOT: AVOID inotropes

b-blockers

fluid resuscitation

 

 

Restraint with Restraints

Medical duty of care – restraints required to complete medical responsibilities safely

RED form

Mental Health Act forms – must notify on-call psychiatrist

Document forms + in patient notes, maximal time for medical review is 4 hours – review of restraints must also be documented on forms and in notes

“Consent” – must inform patient or next-of-kin of use of restraints, document “consent” or why obtaining consent was inappropriate

Mechanical Restraint Presentation

Winter’s Wrap 25.10.2017 – CTB, HOCM, Decision making

To scan or not to scan – Dr Mike Gibbons

Ordering of CT brain for trauma without radiology registrar approval – consider whether other imaging is required ie: Cervical spine or facial bones

Consideration of anti-platelet therapy as a risk factor for occurance or increased size of intracranial haemorrhage

Low risk of delayed bleed in anticoagulated patient and bleed may occur up to 2 weeks after initial trauma so admission for repeat scan is not usually indicated

Ensure clear documentation of decision to scan or not to scan and that appropriate discharge instructions are given to patient and carer

 

 

HOCM and the bands – Dr Hans Hollerer

Dynamic presentation of HOCM:

Left Ventricular Outflow Tract obstruction

Mitral regurgitation

Diastolic dysfunction

Arrhythmias

 

LVH

“dagger-like” Q waves in lateral and inferior leads

atrial enlargement

atrial tachycardias – AF, SVT

 

 

Treatment of collapse in HOCM:

Increase PRELOAD and AFTERLOAD

IV fluids

elevate legs

IV b-blocker

NOTE: Metaraminol contraindicated in structural heart disease

 

Other key points:

  • Tamiflu – reduces symptoms by 3 days, indicated in first 48 hours in some populations
  • “Band forms” on blood film – white cell progenitors pushed out of bone marrow, indication of early stages of sepsis
  • “The blue book” – communicable diseases, incubation, notifiable illnesses

https://www2.health.vic.gov.au/getfile/?sc_itemid=%7b7A1F05A1-64B0-4B8C-A730-D4F8F107AA52%7d&title=The%20blue%20book

 

 

“It is in moments of decision that your

destiny is shaped”

Decision Making – Dr David Mai

heuristics and metacognition
croskerry - cognitive forcing strategies (1)
croskerry - cognitive debiasing 2
croskerry achieving quality in decision making
croskerry - cognitive forcing strategies

 

winter’s wrap 27.09.2017 – Fascia Iliaca block, pneumothorax

Fascia-Iliaca Block – Dr Liz Wyatt

remember your anatomy! use anatomical landmarks then confirm with US…identify vessels, move laterally, identify iliacus muscle and position needle deep to fascia lata

volume is the key! Ropicavaine 1-3mg/kg diluted to 40ml with N/Saline

document local anaesthetic, dose and time in notes and on medication chart

see Liz’s presentation here

Pneumothorax – Dr SzeChi Freidanck

British Thoracic Society Guidelines – small < 2cm at hilum

Western Health Respiratory and Thoracics Units Guidelines:

1)      Large pneumothorax which is chosen to be treated conservatively (asymptomatic patient)  and for primary VATS must be discussed with the Thoracic Registrar/Consultant and booked into their clinic for review in 1 week

2)      Conservative treatment (small/moderate) asymptomatic : a period of observation in EOU then followed by repeat X-ray prior to D/C is a safe plan: Respiratory Clinic follow up

3)      Symptomatic patients should have an intervention: small bore catheters/Pig tail catheters: acceptable choice

4)      Complications following intervention should be looked for :bleeding/catheter blockage, and transfer patients are at risk of complications (Footscray remains the preferred destination for any patient with ICC/catheter)

5)      Complete/Total lung collapse/Radiological signs of Tension Pneumothorax = prompt intervention= ICC

Winter’s Wrap 20.09.2017 – Procedural sedation, intubation, endocrine emergencies, pharmacy

Procedural Sedation

Check the Western Health Policy on procedural sedation for revision

Chose the ideal cocktail for this patient and this procedure

Titrate dose to the patient and duration of sedation – remember they may slip into general anaesthesia without the painful stimulus

Note changes in ETCO2 waveform and absolute value

Use a checklist and document

 

Intubation Checklist

Dr Chandimar Surangi

 

Endocrine Emergencies

Dr Su Pham

 

The IRCMAC and legal prescribing

Pharmacist Jo Edwards