Tag: disaster

Sep 4 2019: St Vincent’s regional teaching

Regional teaching -ST vincents Hospital 4/9/19 with thanks to Dr Rasanga Peiris

It was interactive scenarios with small group discussions. These were the answers we came up with & there may be more correct answers

  1. Disaster management

There was a rail track accident at Parliament station and AV calls on a Wednesday Morning. ED is full.

Preparation broadly categorise to :          Stuff                     Space                    Staff

Space

Vacate resuscitation for critical pts – send people to ward, discharge lounge, home.

Expect minor traumas and walk-ins – designated fast track area

Staff

Inform relevant disciplines, Director. Activate code brown.

Theatre – cancel the electives                    Inform blood blank and Radiology

Delegate staff –set teams in each bay. One Ed consultant/ reg to the triage.

Stuff

Source Ventilators, plasters, IV poles, Dressing/trauma packs.

Need extra drugs ( Iv morphine, fentanyl, cefazolin , fluids, inotropes)

 

Toxicology

50 Y M vomiting, SOB, Blurring of vision and chest pain. Etoh ++ last night

Obs -PR 110 RR 28   BP  130-90   spo2 97%   GCs 14 drowsy with slurred speech

pH7.21                  HC03  10               pCO2    18            glucose  7            urea 15

sodium 145         K   4.5                   Cl 105                    Lactate 5              OSm 335

Breath alcohol 0.01%

Agent – likely a toxic alchol – HAGMA + increase OSmolar gap + low alcohol levels

*oral & IV alcohol             * Iv sodium bicarbonate                               *formipazole                     * Iv fluids

 

Young girl ingested Amyl nitrate a night club instead of sniffing it. She presented with SOB + hypoxia.

Her blood gas was given & had a methaemoglobin level of 38%

* O2 via venture               *Methelene blue

 

A young male has tachycardia with hyperthermia with exaggerated reflexes and a clonus : Serotonin syndrome

*cooling active (cold fluids & bladder irrigation ) & passive (Ice packs around the body with a body bag )

*benzodiazepines                           *cyproheptadine

 

Echo: Fluid responsiveness during shock

LVOT VTI (Velocity time integral) normal 15-20cm  – better determinant of fluid responsiveness rather than EF

*VTI is based on LVOT stroke volume                    * gives a quantitative measure

  • Apical 5 chamber view
  • Get a doppler graph (PW) of the LVOT -draw and get the height of the blood column
  • Get someone to raise leg to increase the venous return & repeat VTI – if VTI increases : fluid responsive

 

Shoulder reduction techniques:

Explain the pt the option of using each technique and it’s ok to expect to transition to using sedation if the shoulder is still not in. You need compliant pts. Fractured NOH cannot be reduced without surgery.

Cunningham https://litfl.com/cunningham-shoulder-technique/

  • Best for when humeral head is up under acromium and biceps is causing tension aim to massage biceps. Relax pt and bring shoulder blades back to open joint
  • Pt is usually holding arm flexed to body.

Kocker’s method https://www.youtube.com/watch?v=2wiIlT6_YLM

  • Best when humeral head is under glenoid and there is a step in deltoid muscle area.
  • Pt is usually holding arm down by side

Spaso https://litfl.com/spaso-technique/

  • One of the ‘zero position’ techniques aim to align muscles and bring the shoulder back.
  • Pt lays back, gentle straight traction on wrist, supinate arm once brought forward.

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

 

EMCrit RACC Podcast 219 – Critical Burn Patients in the ED/ICU – Part I with Dennis Djogovic

EMCrit RACC Podcast 221 – Burns Part II with Dennis Djogovic – Airway, Lungs, Tubes and Stuff

 

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

Disaster Medicine Review

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