1. ED Orientation Part 2
Breathing + Circulation

2. Asthma
Bad asthma
What are you going to do?

3. Bad asthma
Salbutamol - back to back nebs – oxygen driven
Ipratropium neb
Steroid eg prednisone
IV salbutamol
BiPAP eg 10/2cmH2O (continue nebs via BiPAP)
Rarely ketamine – senior doc
Nebulised adrenaline
IV magnesium is probably out for adults (but life threatening
asthma was excluded from the trial), probably works for kids
http://stemlynsblog.org/2013/05/jc-does-magnesium-work-in-
asthma-st-emlyns/

4. CXR +/- or U/S to rule out pneumothorax

5. COPD
Bad COPD What are you going to do?

6. COPD
Work out ceiling of care
Nebuliser
BiPAP eg 10/5.
Continue neb via BiPAP
Steroids
Antibiotics if productive cough

7. Wheezy babies
Working hard to breath
What are you going to do?

8. Wheezy babies
< 3 months consider congential heart disease
< 1 year = bronchiolitis
> 1 year = wheezy bronchitis, or if recurrent =
asthma
Any age: consider foreign body - but very rare

9. Wheezy babies
Rinse nose with saline
Oxygen in sats < 92%
< 6 months: don't use ß agonist or steroids
< 1 year: if family Hx of atopy try ß agonist
6 puffs via spacer q20 min.
If no objective improvement stop using
No steroids
> 1 year and working very hard or hypoxic
ß agonist and steroids

10. Wheezy babies
Admit if
RR > 60
Unable to feed
Sats < 92% on RA
Poor social situation

11. CCF
Bad CCF
What are you going to do?

12. CCF
GTN 1-2 puffs SL PRN q5min if BP will tolerate
BiPAP or CPAP eg 10/5
? Frusemide if fluid overloaded
GTN patch or infusion if required
Can't do infusions on ward :-(
Early use of ACEI

14. The highest rib space that can be easily felt in
the axilla.
Spontaneous: long needles eg central line
needle, 16 G angiocath
Trauma: finger thoracostomy: big cut with a
scalpel, then a finger in the hole to ensure you
are in the space.

16. http://lifeinthefastlane.com/2011/04/own-the-
chest-tube/

17. “Moderate” pneumothorax can be aspirated eg
via long IV cannula but …Most often we are
putting in a 14Fr chest drain using Seldinger
technique
Video:
http://www.cookmedical.com/cc/datasheetMedia.
do?mediaId=4490&id=5392
Major trauma we will usually put in a 32Fr chest
tube by open technique - but this will change
over time - to smaller Seldinger drains.
We have 32Fr Seldinger sets.

18. If you have time - lots of long acting local
anaesthetic into the chest wall and pleural space
+ IV analgesia / procedural anaesthesia

19. C

20. All ECGs read by doctor as soon as they are
taken
Written interpretation
Time
Legible name
We will go through some key ECGs in the ECG
session and the syncope session

21. STEMI
Thrombolyse in ED
Streptokinase or Tenectoplase
Follow the ACS pathway

22. Syncope or new seizure
ECG
See http://emtutorials.com/2013/05/syncope-
beardsell-semep/

23. Temporary treatment for
hypotension

24. Push dose pressors
Phenylephrine: pure alpha = vasoconstrictor without
tachycardia
10mg of phenylephrine in 100ml normal saline =
100µg/ml

25. Push dose pressors
Adrenaline/epinephrine
Vasoconstriction + increased cardiac
contractility
Risk of tachyarrythmia
1 ml of 1:10,000 (100mcg) made up to
10ml with normal saline = 10mcg/ml 0.5-
2ml push

26. Tox ECG
Specific things to look at on the ECG of a patient
with a potential overdose.
These are covered in the tox talks Eg
http://emtutorials.com/2013/05/toxicology-for-
pgy12/

29. Shock
No single sign or test
Hypotension
Increased capillary refill time
Shut down peripheries
Raised lactate
Tachypnoea
Tachycardia
Decreased urine output (get a catheter in early)
(+/- IVC filling and cardiac contractility by u/s)

30. Types of Shock?
Volume loss
eg haemorrhage, 3rd spacing
Obstruction
eg PE, tamponade
Pump failure
eg MI, CCB overdose, sepsis, valve pathology
Vasodilation
eg sepsis, overdose, anaphylaxis, neurogenic

31. Shock
NZ is a civilised country and so very little
penetrating trauma

32. Shock
Use all your clinical skills to work out what is
going on
Consider a wide range of causes.
All hypotension in trauma is not hypovolaemia
Pneumothorax
Tamponade
Neurogenic shock (diagnosis of exclusion)
Use ultrasound: pneumothorax, blood around
heart, blood in abdo

33. Haemorrhagic shock
Trauma
Haemorrhage
on the bed,
in chest,
abdo,
pelvis,
long bone
Tension pneumothorax, tamponade
Clinical exam + ultrasound + XRay +/- CT

34. Haemorrhagic shock
Use blood products early
Minimise use of crystaloid / colloid
O-negative blood available in minutes
FFP takes half an hour to thaw - request early
Platelets come by taxi from 1 hour away
Use tranexamic acid 1g IV over 10 minutes then
1g IV over 8 hours

35. Non haemorrhagic shock
Treat specific cause
If not sure: 500ml - 1L of saline likely to help

36. IV Access
If you have failed to get an IV line in a patient
after 2 goes be nice to yourself and the patient
and get someone else to try.
We all have off days.
Remember the interosseous needle for adults or
kids

37. http://www.vidacare.com/admin/files/T427RevC-Insert-RemPoster.pdf