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
- 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
Vacate resuscitation for critical pts – send people to ward, discharge lounge, home.
Expect minor traumas and walk-ins – designated fast track area
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.
Source Ventilators, plasters, IV poles, Dressing/trauma packs.
Need extra drugs ( Iv morphine, fentanyl, cefazolin , fluids, inotropes)
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 )
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.
- 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
- 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.
Organ Donation – Dr Forbes McGain (Intensivist)
Brain Death vs Circulatory Death
Clinical Testing – normothermic
– Sedating drugs excluded – *Baclofen mimics brain death
– cranial nerve testing
– Apnoea test
Imaging – if inappropriate for clinical test, unstable, spinal reflexes present
Contact Donor Coordinator – ICU registrar or Consultant, or Donate Life via switchboard
Initiate conversation but ensure family aware ICU attendance is NOT too prolong life but for consideration of organ donation
consider for donation if: Brain death or imminently dying and withdrawal of cardiorespiratory support planned
Intubated and Ventilated
BP adequate for organ perfusion
No Malignancy or HIV
Age 1-80 years
Contrast Nephropathy – Dr Jamie MacGilivray
Variable definition of nephropathy
Jamie’s audit showed 16 patients actually had improvement in renal function!!
In summary – understand the clinical indication for the scan requested and the timeframe within which results are needed. Renal function should not delay an appropriate CT.
Paracetamol Overdose – Dr Deb Maher
Guidelines for writing SAQs…for registrars presenting at Footscray to incorporate into their presentation:
Review Dr Shona McIntyre’s presentation on toxicology (36min)
Review the Scared Weird Little Guys guide to toxinology (2min)
Review pressure immobilisation bandaging (2min)
Due to time restrictions Dr McIntyre had to omit a case study from the presentation which are provided below:
HMO toxicology addendum
Thanks to local legend Dr Zeff Koutsogiannis who gave two presentations related to toxicology.
UPDATE 26/9/17: Thanks to Dr Neil Long FACEM for providing audio for these talks
Murder she wrote (or toxicology and the blood gas)
Masterchef (or cardiovascular toxicity in the poisoned patient)
Slides only versions:Murder,she wrote (Western teaching)
Cardiovascular Toxicity in thepoisoned patient (Western teaching)
A great turnout for the first Footscray session!
A massive thanks to Dr Zeff Koutsogiannis for enlightening us on the usefulness of ABGs and cardiotoxic drug ingestions.
6 easy steps
causes of metabolic acidosis – CAT MUDPILES (you fill it in!)
osmolar gap – make sure osmolality and UEC are requested at the same time
lactate gap – compare the lab lactate measurement with blood gas machine measurement, consider “glycolate” a metabolite of ethylene glycol
CARDIOTOXIX DRUG INGESTIONS
SALT NaBicarb – give as a bolus in TCA OD (not an infusion)
SUGAR High dose insulin-dextrose to improve pump function in BB and CCB OD
COLOUR Methylene blue for profound hypotension despite fluid, available from theatre 1-2ml/kg/hr
FAT Intralipid only for LA injection with CVS toxicity
QT measurement – 3 limb leads, 3 V leads, take the MEDIAN measurement then plot on QT nomogram to determine likelihood of developing torsades
Thanks Dr An Le for his presentation on ethylene glycol toxicity.
- key ingredient in antifreeze and other industrial products
- any deliberate or significant ingestions are potentially lethal (>0.5ml/kg)
- produces characteristic toxidrome with CNS depression, metabolic raised anion gap raised osmolar gap acidosis and potentially renal failure
- antidote is ethanol
- disposition is usually to HDU