ED med unit one

what vital sign may the be the first sign of clinical deterioration

abnormal RR

what is normal spo2

above 95%

ways to stablize the airway

• head chin tilt

• jaw thrust

• you can use airway adjucts such as

  • oropharyngeal airway, nasopharyngeal airway

  • 
    

head tilt chin lift

moves the tongue from the orgopharynx

when not to use head tilit chin lift

when there is cervical spinal injury

airway adjuncts

• use when pt is unconcious w/o gag reflex prevents tongue from obstructing airway

• measure from corner of mouth to angle of mandibile

• can use bag-valve-mask

nasopharyngeal airway

• helps to maintain airway patency

• can use with conscious pt with intact gag reflex

• aviod in midface, basilar skull face, nasal passage

bag valve mask ventilation - when may it be harder

• when you bag someone hot you moan

MOANS

• mask seal problems like hair

• obesity

• ages above 55

• no teeth

• snoring, stridor, stiff lungs

non invasive postive protective ventilation

• can be used in awakem cooperative pt

• used in respiratory distress w/o need for intubation

• delivers high pressure through tight fitting mask

  • improve o2 and ventilation

what are the types of non invasive pressure ventilation

• bip level postive airway pressure that helps with o2 and ventilation used in COPD

• continous postive airway pressure CPAP-

supralottic airways

• it is invasive, lays just above the vocal cords

• used as a rescue airway when bag is not good enough

• provided o2 and ventilation

• different types include: laryngeal mask airway, i-gel, king laryngeal tube

what can protect from aspiration

• definatrive airway

what are indications for endotracheal intubation

• altered mental statues (GCS less or equal to eight) or high aspiration risk with impaired airway protection

• persistant hypoxia

• anticipiated deterioration (serve neck, laryngeal or facial trauma)

what might make tubing hard

LEMONS (tubing on a leomn floatty)

• L- look externally

• E- eval 3-3-2 rules

• M= mallamati score above or equal to 2

• O obstruction

• N- neck mobility

what is the 3-2-2 rule

•Incisor distance (distance between teeth)≥ 3 fingerbreadths

•Hyoid–mental distance ≥ 3 fingerbreadths (double chin area)

•Thyroid–mandible floor distance ≥ 2 fingerbreadths

Mallampati classiification

•Incisor distance ≥ 3 fingerbreadths

•Hyoid–mental distance ≥ 3 fingerbreadths

•Thyroid–mandible floor distance ≥ 2 fingerbreadths

rapid sequence intubation

• use a sedative agent like (etomidate, katamine, and propanolol)

• then use neuromuscular blockagent like (succinylcholine and rocuronium)

steps for RSI

1.Preparation

• Equipment, personnel, medications, backup airway

2.Preoxygenation

• 100% oxygen to maximize oxygen reserves

3.Induction & Paralysis

• Sedative followed by neuromuscular blocker

4.Endotracheal Intubation

• Perform laryngoscopy

• Visualize the vocal cords

• Advance the ETT through the cords

5.Confirm Tube Placement

• Continuous waveform capnography (gold?)

• Bilateral breath sounds

• Chest x-ray for tube depth

6.Postintubation Management

• Ventilator

• Sedation/analgesia

• Ongoing reassessment

SOAPME checklist for tubing

Suction –  ensure working

Oxygen – nonrebreather, BVM, HFNC

Airway

oETT: 7.5 most adults, 7.0 smaller women, 8.0 larger men

oStylet placed inside ETT for rigidity

oLaryngoscope handle or video laryngoscope

oMacintosh (curved) or Miller (straight) blades

oBougie available as backup

Pre-oxygenate

Monitoring equipment and medications

oECG, vital signs, pulse ox, induction and paralytic meds

End tidal Co₂ detector

why do we pre oxygenate

•Creates an oxygen reservoir before apnea

•Prevents hypoxia during intubation attempt

•Extends safe apnea time

how to preoxygenate

•3–5 minutes of 100% oxygen

•Options:

oNon-rebreather mask (NRB)

oHigh-flow nasal cannula (HFNC) if available

oBag-valve-mask

what setative in RSI can cause hypotension

propofol

which paralyric has longer duration

rocuronium `

ETT size

•Adult female usually 7.0-7.5 mm

•Adult male usually 7.5-8.0 mm

ETT depth

•Women: ~21 cm at the teeth

•Men: ~23 cm at the teeth

ETT cuff

•to form a seal against trachea

•Prevents air leak

•Reduces aspiration of gastric contents

ways to get immediate varifcation for ETT tube

•Direct visualization of the tube passing through the vocal cords

•Colorimetric ETCO₂ detector (if used)

Indicates presence of exhaled CO₂

•Bilateral chest rise

no epigastric sounds `

what is the gold standard for confirming tracheal placement

•Continuous waveform capnography (gold standard)

oPersistent ETCO₂ waveform confirms tracheal placement

oNo waveform or minimal ETCO₂ suggests esophageal intubation

what to do after tube placement has been confirmed

• secure the ETT with tape

• ventilator managament

• reasssess o2 and ventilation, hemodynamics and waveform capnography

when does the american collage of cardiology rec o2 for ACS

when less than 90%

slide

51

what are ways to deliver o2 from least to greatest

• nasal cannula

• simple face mask

• venturi mask (controlled FiO2)

• high flow nasal cannula

• bag valve mask

breathing distress

•Increased work of breathing

•Accessory muscle use/retractions

•Still maintaining oxygenation and ventilation

•Patient is compensating

respiratory failure

•Compensation is failing

•Unable to maintain oxygenation and/or ventilation

•Patient is tiring → prepare to intervene (for ex silent chest)

pt when low respiratory efor and confused/ obtunded

respiratory faluire

respiratory distress tx

•Supplemental oxygen if hypoxemic

•Titrate oxygen to lowest flow rate that maintains target saturation

•Consider NIPPV (BiPAP/CPAP) when appropriate

•Treat the underlying cause

respriatory failure tx

•Support oxygenation and ventilation

•BVM if ventilation is inadequate

•Consider NIV in selected patients who can protect their airway

•Prepare for intubation/mechanical ventilation if worsening or support is inadequate

for apnea and agonal respirations

•Immediate BVM ventilation with high-flow oxygen

•Prepare for definitive airway

how to maintain circulation inital management

• monitor cardiac, BP, pulse

• establish 2 large bore peripherial IV if shock and IO acess

• begin resuscitation

IV fluid what are we giving

???

physical exam for physical wounds

• inspection

• neurovascular assesment

• functionial assessment (joint, tendon)

• consider imaging

factors that delay wound healing

§ Diabetes mellitus

§ Peripheral vascular disease

§ Immunosuppression

§ Smoking

§ Poor nutrition

§ Foreign body or retained contamination

§ Previous keloid formation (cosmetic consideration)

what wounds are hgher risk

• Delayed presentation

• Crush or puncture wounds

• Bite wounds 

• Heavy contamination (soil, feces, organic material)

• Lower extremity or perineal wounds

• Diabetes or immunosuppression

what wounds are low risk

face and scalp

obtain imaging

imaging for met

imaging for wood, plastic, other radiolucent

ultrasound

imagning for complex

CT

when to use lo

high pressure irrigation

contaminated or high risk wounds and is used 30-60mL syringe plus 18G cather/ irrigatioin

systemic absorptioin

peripheral nerve blocks

-Better pain control

-No wound distortion

-Helpful for fingers, toes, face

debridement

removal of devitalized tissue (tissue that is grey/black or does not bleed when cut) and retained debris

hair removal

not needed for debridement and may increase infection risk, if needed clip 1-2mm above skin

primary closure

• close in the acute phase (less than 12 hrs or less than 224 in face) only down or clean wounds with low infection risk

primary closure CI

animal bite, forgein material, neurovascular comprimised, deep structed damage

delayed primary closure

for wound with high risk irrigation is done first and closure 4-6 days laters once clean and no sign of infectioin

secondary intention

where a wound is left open for the body to heal it from base upward through granulation & epithelilization it is done for wound presenting late or with lots of tissue loss, heals slower, higher infx risk, and scar is worse

adhesive tape/ steri strips technique

cheap, painless and fast -Clean and dry wound

Apply tincture of benzoin to improve adhesion, Approximate wound edges

Apply strips perpendicular to the wound

adhesive tape/ steri strips CI

• over a joint

• wound that require layered closure

• hgh moisture areas like the axilla and groin

• poor adheson (hair, oil, drainage)

adhesive tape/ steri strips indications

Linear, low-tension wounds (< 2 inches long)

Superficial wounds

Fragile or thin skin (elderly skin tears)

Often used as adjunct with sutures

tissue adhesive

Dermabond, Liquiband

tissue adhesive indications

Linear, low-tension wounds

Superficial wounds

< 4 cm length

tissue adhesive CI

High-tension wounds (gaping or over joints)

Active infection

Mucosal surfaces, skin exposed to body fluids or with dense hair

stapes indications

Scalp lacerations

Linear trunk lacerations if cosmesis not priority

staples CI

Gaping wounds with layered closure

Areas with high-priority cosmesis

staples technique

Clean and prep wound, local anesthesia

Evert wound margins with forceps/fingers

Place 1^st staple at center of wound using staple gun

Continue bisecting with staples until well approximated

sutures CI

Heavily contaminated wounds

High risk of infection (puncture wounds)

Non cosmetic animal bites

High risk of tissue destruction (high pressure wounds

sutures indicationis

Clean wounds with low risk of infection

Areas of cosmetic concern

Wounds over tendons or nerves

what are the suture types

Absorbable (gut, Vicryl) and Nonabsorbable (nylon, Prolene)

when should wounds be given abx

• Animal or human bites

• Gaping intraoral lacerations

• Grossly contaminated wounds

◦Water exposure

◦Soil or fecal contamination

wounds that are tentus prone

• over 6 hours

• deeper than 1 cm

• missle, crushed, burn, frosbite

• if infection is present

• if devitalized tissue present

• dirt ect present

• denervated or ischemic tissue present

tetanus review

Caused by Clostridium tetani

Neurotoxin causes severe muscle spasms

Preventable with immunization series (3-dose primary + boosters)

Dtap

given to children less than 7 yrs completing the primary series

Tdap

one time adult dose

Td

• booster every ten years

• every five for a tetanus prone wound

TIG

tetanus immune goblin is given to pt when primary vaccine is incomplete or unkown for passive immunity

wound care pt instructions

•Keep dry for first 24 hours

•Wash gently with soap and water after 24 hours

•Avoid soaking until healed

clean dressing daily

when should pt return ater wound care

•Increasing redness, swelling, warmth, drainage, or fever

•Persistent bleeding

•New numbness, weakness, or loss of function

•Wound separation

lacerations on extensor tendon l

•Examine joint in position of injury

•Assess active extension at MCP, PIP, DIP

•Loosely approximate skin, splint in functional position

•May be repaired in ED if provider experienced

Refer to hand surgeon

lexor tendon laceraton

•Examine joint in position of injury

•Assess active tendon flexion at each joint

oFDS tendon flexes PIP joint

oFDP tendon flexes DIP joint

•Do not repair in the ED

•Loosely approximate skin, splint in functional position

•Hand surgery follow-up within 1–2 days

fight bite fist injury

• do not suture closes

• amox clav

• close follow up

fingertip injury

• always remove rings

• if skin an pulp only can do concerative care if there exposed bone abx, splinting and urgent hand surgeon referral

subungual hematoma

-trephinate can be very painful injury

what foreign body can be left

small inert and asymptomatc

what foreign body must always be removed

organic (wood, thorns, painful, neurovascular comprimise

puncture wounds

• tx 1 gen cephalosporin

• if went through shoe than tx cipro cause fq needed or pseudomonas rsk

cellulitis

• non defined

• tx- cephalexin or dicloxacillin

• recheck in 448-78 hrs

cutanous abscess

• hallmark is fluctuance on exam

• V drug use ncrease risk for reccurance, MRSA, and systemc infection

cutanous abscess tx

•Incision & drainage (I&D) = mainstay

•Antibiotics not required unless: fever, multiple/large, immunocompromise, IVDA, extensive surrounding cellulitis

•Options for MRSA: TMP-SMX, doxycycline, clindamycin

paronychia

• soft tissue infection of the nail fold

• pain worsen with pressure

• tx warm soaks with abx (if cellulitis, immunocompromsed, or serve fx

• if there is an abscess lift the nail fold and drain

when can bites be primary closed

Facial/scalp wounds

•Simple dog bites

•<6–12 hours old

•Well irrigated, minimal contamination

•Healthy (not immunocompromised) patient

 Avoid primary closure

•Cat or human bites

•Hand or foot wounds

•Deep puncture wounds

•Gross contamination or devitalized tissue

pasteurella multocida

cats

•Eikenella corrodens

humans

Dog bites involving the hand, deep puncture wounds, or near joints pathogen

•Pasteurella multocida

what bites get abx

• cats

• human

• primiary closure

use amox clav 3-5

Superficial

§Epidermis only

§Red, dry, no blisters

§Painful