Month: April 2016

Circulation

Tank. Clogged Pipes. Broken Pipes. Pump.

Introduction

  • “Tank”
    • Hypovolemic shock
    • Hemorrhagic shock
  • “Clogged Pipes”
    • Cardiac tamponade
    • Tension pneumothorax
    • Pulmonary embolism
  • “Broken Pipes”
    • Septic Shock
    • Neurogenic Shock
    • Anaphylactic Shock
  • “Pump”
    • Cardiogenic Shock

Step 1: Fill the Tank

  • Establish an IV
    • IO line alternative in emergent situations

Step 2: Consider Clogs

  • Cardiac tamponade
    • Diagnosis: Ultrasound
    • Treatment: Pericardiocentesis
  • Tension pneumothorax
    • Diagnosis: Clinical/Xray/Ultrasound
    • Treatment: Needle decompression and tube thoracostomy
  • Pulmonary embolism
    • Diagnosis: Clinical/CTA
    • Treatment: Thrombolytics

Step 3: Squeeze the Pipes

  • Administer vasopressors
    • Most common: Norepinephrine
    • Alternatives: Epinephrine, Phenylepherine

Step 4: Analyze the Pump

  • Get an EKG
    • Ischemia = Aspirin/Heparin/Cath lab
    • Dysrhythmia = Electricity

Additional Reading

Breathing

Hypoxemia fixed by only TWO things: FiO2 and PEEP

Step 1: Add FiO2

  • If the patient is breathing…
    • Nasal cannula
    • Non-rebreather mask
  • If the patient is NOT breathing…
    • Bag-valve mask

Step 2: Add PEEP

  • *Cannot be completed in 60 seconds, but equipment can be requested
  • If patient is breathing…
    • BiPAP
  • If the patient is NOT breathing…
    • Intubation

Additional Reading

Airway

“Airway” does not necessarily mean “Intubation”

Introduction

  • In emergency medicine we are taught “A-B-Cs”
    • These are actions that can be accomplished in first 60 seconds of patient encounter
      • Intubation takes several minutes to accomplish
      • Intubating a crashing patient might even KILL them!
    • Resuscitate THEN intubate

Step 1: Suction

  • Immediately suction if patient is…
    • Altered and vomiting
    • Gurgling

Step 2: Move the Tongue

  • Bedside maneuvers
    • Head tilt
    • Chin lift
    • Jaw thrust
  • Adjunct equipment
    • Oropharyngeal airway
    • Nasopharyngeal airway

Additional Reading

Epistaxis

Don’t forget to wear protective gear. Gown up!

Initial Encounter

  • History
    • Anticoagulants
    • Easy bleeding/bruising
    • Lightheadedness
  • Exam
    • Pallor
    • Tachycardia/Hypotension

Step 1: Put on Personal Protective Equipment

  • Gown
  • Gloves
  • Mask
  • Eye Protection

Step 2: Clear Nose and Visualize Bleeding

  • Have patient blow out/remove any clot and look for source of bleed
  • Kiesselbachs plexus
    • “Anterior” epistaxis
  • Sphenopalatine artery
    • “Posterior” epistaxis
      • Most severe/dangerous form

Step 3: Spray In Oxymetazoline (Afrin)

  • Hold pressure for 15 minutes after initial application

Step 4: Cauterize With Silver Nitrate

  • Avoid bilateral cauterizations
    • Can cause septal perforation
  • Anesthetize as necessary
    • 4% lidocaine on gauze and leave in nose for 10 minutes prior to cauterization

Step 5: Pack the Nose

  • Multiple commercial products available for this
  • The utility of antibiotic prophylaxis at this step is unclear
  • Patient goes home with packing in place

Additional Reading

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