Emergency Med Simulation Notes

ABCDE

AIRWAY

BREATHING

CIRCULATION

DISABILITY (NEUROLOGICAL)

EXPOSURE

Airway

- Can pt speak?

- Upper airway obstruction --> think Reposition, Remove FB, Intubation

Breathing

- B/l Breath sounds - check for tension pneumo --> consider Needle decompression (2nd ICS, MCL or 4/5th ICS, AAL)

- Check pulse ox

- Check pt's availability to ventilate

Circulation

- Check central pulse: Carotid, Femoral

- Check peripheral pulse

- Heart beating? CPR? Dysrhythmia?

- Establish IV Access: Peripheral IV, Central Access, Intraosseous Line

- IV Fluids?

- Transfusion if bleeding

Disability

- Glasgow coma scale

- Signs of brain or spinal cord injury

Exposure/Environment

- Expose pt

- Log roll

- Evaluate back, crevices

- Keep pt warm to prevent hypothermia

Nasal cannula

- FiO2 35-45%

- Delivers 1-6 L/min

- For general oxygen needs, COPD

Simple face mask

- FiO2 35-50%

- Delivers 6-10 L/min

- For general oxygen needs

Non-rebreather (Face mask w/ a reservoir bag)

- FiO2 80-95%

- Delivers 10-15L/min

- For High O2 EMERGENCY needs

High Flow Nasal Cannula

- FiO2 up to 100%

- Delivers up to 60L/min

- For High O2 EMERGENCY needs

CPAP

- FiO2 up to 100%

- For COPD exacerbations, cardiogenic pulmonary edema, etc.

- Has been shown to decrease intubation

- NOT for delirious or agitated patients due to risk of aspiration

Hypovolemic/hemorrhagic shock

- Maximize O2 delivery

- Control further blood loss

- Fluid resucitation

Acute setting blood transfusion

- 1-2 units type O Rh-negative blood

- PRBC:FFP:Platelets = 1:1:1

Tension pneumothorax

- Needle decompression if unstable

- 4th/5th ICS Anterior Axillary line

- Chest tube after

If suspect Abd Visceral injuries,

If trauma but no blood on scene, may be bleeding internally

- FAST exam (check heart, RUQ, LUQ, Pelvic)

Blunt Trauma pts w/ AMS, looking bad, can't get info out of them

Pan-scan (CT) - check head, spine, chest, abd/pelvis

3% Hypertonic saline

- 1st bolus 100mL over 10 min, if no response 2nd bolus 100mL over 50 min

- For seizures, coma, focal findings, symptomatic hyponatremia

0.9% NaCl

- 1 to 2 L bolus (optional), followed by 150 to 300 mL/hour for 24 to 48 hours or until euvolemic (421 rule)

- Dose guided by clinical assessment. In pts w/o heart failure or kidney impairment, the usual dose range is ~3 to 6 L of fluids in the first 24 to 48 hours

- SHOCK FROM ANY CAUSE

- HEMORRHAGE

- BURNS

- IN CONJUNCTION WITH BLOOD TRANSFUSIONS

0.45% NaCl

- Hyperosmolar states d/t severe hyperglycemia

- Hypernatremia w/ ECFV depletion

Dextrose 5% in Water (D5W)

Dehydrated patients with NORMAL BP

Aortic rupture

- CXR shows widened mediastinum

- Diagnostic test of choice: CT Angiography

Abd Visceral injuries

- Stable: CT abd w/ IV contrast

- Unstable: go to OR

Livery injury

- MC injured abd organ

- MC injured in penetrating trauma (Small bowels second)

- Suspect with lower right-sided rib fractures

Splenic injury

- 2nd most commonly injured

- Suspect with left lower rib fractures

Pelvic trauma

- Severe fx can bleed heavily

- X-ray, then CT pelvis

- Pelvic binder

Pregnant pts

- Displace the uterus to the LEFT

- Insert chest tubes one rib space higher

- Rh negative patients should receive RhoGAM after blunt trauma

Septic shock sources

- Resp tract infection

- UTI

- Soft tissue, GI, GU infections

- Foreign body, fungal infections

- Polymicrobial

Septic shock

- Fever

- AMS: GCS < 15

- Tachypnea: RR >= 22

- Hypotension: SBP <= 100

1) blood cultures before antibiotics

2) lactate

3) IV antibiotics before 60 minutes (single dose of Meropenem 2g, other options available)

4) 30 mL/kg of IV fluids before 180 minutes*

Cardiogenic shock

- MCC is MI

- PCI within 90min

- MONA BASH

- Alteplase 0.9mg/kg IV bolus over 1 min if can't do PCI

Anaphylaxis

- Epi (1mg/1ml) 0.5mg IM, may repeat ev 5-15 min (use if risk of airway, CV compromise)

- Diphenhydramine IM, IV 50 mg once, then every 4-6 hrs PRN; administer after epinephrine

Allergic, Angioedema

- Diphenhydramine IM, IV 10-50 mg every 6-8 hrs PRN

- Famotidine 20 mg IV every 12 hrs

- If antihistamines don't work, use steroids:

MethylPREDNISolone IV 60-80 mg, oral taper over 10 days