Winter’s Wrap 26.04.2017 – Trauma RSI, gastroenteritis, PE

TRAUMA RSI

Thanks to Stacey Turner for a fantastic talk!

    POSITIONING

Collar off and Manual In-Line Stabilisation

Ramping – improve position + view, optimise ventilation and reduce regurgitation

Consider neutral position with head elevated

    SHOCKED TRAUMA PATIENT

Pretreatment – PREVENT ANY HYPOTENSION

Fluid bolus

Reduce haemorrhage – splint long bones + pelvis

Treat other causes of traumatic shock – eg: tension pneumothorax

Pressors: Adrenaline dilute 1:10,000 to 10ml and give 1ml (10mcg) boluses

Drugs – consider NO induction agent in peri-arrest as ALL will drop BP

GO LOW with induction agents:

Ketamine: 25-50% standard dose = 0.5mg/kg

Propofol: 10% standard dose

GO HIGH with paralysing agents:

Rocuronium: 1.2-2mg/kg

 

    NEUROTRAUMA RSI

Prevent secondary brain injury due to raised ICP as as a result of hypertension BUT any episode of HYPOTENSION is associated with increased mortality….

Non-Drug

head up

collar off to improve venous drainage

gentle intubation – video laryngoscopy

Drugs

BEfore:
  1. Antiemetic – ondansetron
  2. Analgesia – eg: fentanyl
  3. Antihypertensive – eg: esmolol
during:
  1. High dose fentanyl – 3-5mcg/kg
  2. Propofol or ketmine
  3. “Ketofol”
  4. Thiopentone
  5. Rocuronium – no fasciculations which may elevate ICP
after:
  1. Propofol + Fentanyl – don’t forget analgesia!
  2. Morphine + Midazolam

 

Registrar Presentations

Excellent music selection!

Gastroenteritis in EOU – Dr Jason Kollios

Only 2 out of 40 patients had altered assessment, but unsure if more patients’ diagnosis altered as may be changed on EDIS

Consider definition of GASTROENTERITIS – diarrhoea, vomiting…if these not present MUST consider an alternative diagnosis

We need to improve education of patients regarding reducing transmission on discharge.

 

Pulmonary Embolism – Dr Ali Alobaidy

Criteria for thrombolysis in Massive PE:

  • systolic BP <90mmHg for >15 min
  • high pretest probability of PE and RV dysfunction on bedside echo

http://thorax.bmj.com/content/58/6/470

http://www.nejm.org/doi/pdf/10.1056/NEJMoa1302097

nejmoa1302097

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