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.