CHEST DRAINS

 

TENSION DECOMPRESSION: FINGER THORACOSTOMY

  • The way forward with Tension PTX Decompression

Sydney HEMS

 

PLACING CHEST DRAINS

 

safeTriangle_v2_default.jpg

 

OPEN CHEST DRAINS

Demonstration of the Insertion of an Open Chest Drain (HEFT EMCAST)

BIGGER IS NOT BETTER, 28 FR FOR TRAUMA IS AMPLE

 

SELDINGER CHEST DRAINS

Demonstration of the Insertion of a Seldinger Chest Drain (HEFT EMCAST)

SECURING THE DRAIN:

ALL DRAINS SHOULD HAVE A HOLDING SUTURE PLACED

THE 'DOUBLE D' TECHNIQUE IS AN EASY EXAMPLE

 

THE ADHESIVE FIXATION DEVICES WE'RE USING FOR THE NEXT STEP IN SECURING THE DRAIN

SECURING A CHEST DRAIN (KEVIN HENSHALL)

static1.squarespace.com.jpg

 

"THE DOUBLE HALF HITCH / double d" TIE

SUTURE TECHNIQUE (BETWEEN 5.20 - 6.25 MINS)

 

CHEST DRAIN PLACEMENT (VIDEO VIA EM IN 5)

 

OTHER DRAIN INSERTION TIPS

HAVE A LOOK AT THE BOOGIE ASSISTED CHEST DRAIN FROM:

TAMING THE SRU

 

Scott Weingart's Take on Things

NEEDLE VS KNIFE (EMCRIT)

 

SMALLER IS BETTER!

QUIZ

Photo by Rawpixel Ltd/iStock / Getty Images

Photo by Rawpixel Ltd/iStock / Getty Images

The last session of CME is a quiz session. 

We are going to divide into teams and participate in a quiz. 

Prizes will be awarded !!!.

Bring you general and medical knowledge and have some fun !!!!!!.

 

SYNCOPE, THE ALTERED & THE AGITATED

SEIZURES - March 29th 2016

SEIZURES March 29th 2016

Seizures Seizures Seizures of all shapes and sizes !!

 

Starting with the "little people" we are going to review paediatric seizures - febrile, afebrile and seizure mimics.

 

We move on the the "grown ups" with a discussion on what to do with the first episode of seizure.

Then finish up with the dreaded STATUS EPILEPTICUS.  What to do when they just won't stop fitting

 

 

READING FOR THIS SESSION

 

 

 

RESPIRATORY, NIV & COPD

TUES 22ND MARCH '16

We'll be looking at Management of COPD & NIV with a practical hands on session with our guest speaker, Ally Hanson, from Teleflex

 

VENTILATING SICKEST OF PATIENTS

 

SOME KEY CONCEPTS TO KEEP IN MIND IF THE WORST CASE SCENARIO ARISES (NEEDING TO TUBE & VENTILATE SICKEST ASTHMATIC OR COPD PATIENT)

 

  • ALLOW PERMISSIVE HYPERCAPNOEA
  • PREVENT AUTO-PEEP, DYNAMIC HYPERINFLATION & BAROTRAUMA
  1. LOW TIDAL VOLUME (TV): 6-8 ml / Kg PREDICTED BODY WEIGHT (PBW)
  2. LOW RESP RATE (RR) 6-10
  3. LOW INSPIRATORY : EXPIRATORY (I:E) RATIO 1:4 OR 1:5
  4. LOW PEEP (0-5)
  5. FLOW RATE 80-100 LPM
  6. FIO2 TO EFFECT

DOMINATING THE VENT WITH WEINGART (EMCRIT)

PROTECTIVE LUNG VENTILATION (LITFL)


ARRHYTHMIAS

Photo by 3DMAVR/iStock / Getty Images

Tuesday 15th March

First Up, to get everyone thinking an ECG quizz. 

 

Then we have a discussion on assessment of tachyarrthymias

Followed by a discussion on the management of bradycardias

At the end we will have some hands on practice with the defibrillator. 

Photo by Dario Lo Presti/iStock / Getty Images

Photo by Dario Lo Presti/iStock / Getty Images

GENERAL APPROACH / TCA & CCB OD / TOX PEARLS

TOXICOLOGY

TUES 16TH FEB '16

 

WE ARE VERY LUCKY TO HAVE CHIP GRESHAM, OUR TOX EXPERT, WHO WILL BE SHARING HIS WISDOM ON THE GENERAL APPROACH TO THE TOX PATIENT ALONG WITH HIS TOX PEARLS

WE WILL ALSO BE COVERING 2 OF THE BIGGIES

  • TRICYCLIC ANTIDEPRESSANT (TCA) OD
  • CALCIUM CHANNEL BLOCKER OD

 

GENERAL APPROACH TO THE POISONED PATIENT

 APPROACH TO THE POISONED (LITFL)

TOXICOLOGY VIDEO LECTURES (ALiEM)

 

KILLER BEES

KILLER BEES

GREAT SUMMARY BY SALIM REZAIE (REBEL EM, @srrezaie)

GREAT SUMMARY BY SALIM REZAIE (REBEL EM, @srrezaie)

Procedural Sedation

PROCEDURAL SEDATION

 

Tues 9th Feb '16

AIMs:

  • Understand the concept of procedural sedation
  • Develop your approach to PREPARATION, which is the KEY
  • Become more familiar with the different drugs available & their pro's / con's
  • Begin to develop your own approach to various scenarios & your options available to complete the procedure
  • Orient to the Paeds Procedure room
  • Hands on & set up of Continous Nitrous 70:30
  • Get amongst a Sedation Simulation in the Paeds Procedure room to consolidate with your hands on
1454041959657.gif

 

 

PRE-READING / LISTENING:

 

A starting point for PREPARATION from EM BASIC

PREPARATION (EM BASIC)

 

More on Procedural Sedation from Scott Weingart & EMCRIT

PROCEDURAL SEDATION (PART 1) EMCRIT

PROCEDURAL SEDATION (PART 2) EMCRIT

PROCEDURAL SEDATION (PART 3) EMCRIT

 

SOME LOCAL DOCUMENTS TO READ THROUGH

Kidzfirst / MMH Guidelines

  • Paediatric Procedural Sedation Guideline:  MMH PAEDS SED
  • Continuous Nitrous Oxide Sedation in Paediatrics:  NITROUS

SEDATION IN CHILDREN (STARSHIP)

 

LITFL Q & A

LARYNGOSPASM WITH KETAMINE

 

A RECENT PAPER ON ADVERSE EFFECTS IN ADULTS

BELLOLIO ET AL, 2016

 

APPROACH TO THE POISONED PATIENT

 

 

Effective and early resuscitation combined with risk assessment and supportive care remain the mainstays of management of the poisoned patient.

Initial evaluation should aim to identify life threats and establish the potential to deteriorate.

 

Consider the mnemonic....Resus RSI DEAD

Resuscitation

  • ABC
  • Check glucose levels
  • Check temperature
  • Manage seizures
  • Consider resuscitation antidotes

 

Risk Assessment

  • Consider potential sequelae

Supportive Care and ongoing monitoring

Investigations

  • General-Paracetamol, ECG, Glucose (PEG)
  • Specific

Decontamination

Enhanced Elimination

Antidotes

Disposition

 

Examination? Easy.

 

 

 

 References and Links

APPROACH TO THE POISONED PATIENT (LITFL)

Calcium Channel Blocker Overdose

Overview

A relatively common and potentially lethal ingestion...and often in a slow release form (eg Diltiazem CR).

Morbidity and mortality is generally due to cardiovascular collapse resulting from a combination of

  • extreme peripheral vasodilatation
  • myocardial depression
  • impaired myocardial conduction.

Extra-cardiac toxicity such as

  • Hyperglycaemia
  • Lactic acidosis
  • Seizures
  • Non-cardiogenic pulmonary oedema

are less common but imply a poorer prognosis.

 

INVESTIGATIONS

Close cardiac monitoring is paramount.

ECG FINDINGS

  • Bradycardia
  • First degree heart block
  • Progressive complete heart block
  • Sinus arrest with node escape
  • Asystole

 

 

MANAGEMENT

Resuscitation

  • A: Intubate if agitated or obtunded (EARLY IS BETTER)
  • B: Supportive
  • C: IV fluid, Calcium, High Dose Insulin, Inotropes, Invasive Monitoring

SPECIFIC TREATMENTS (GRADUATED APPROACH)

  1. Fluid resuscitation, crystalloid
  2. Calcium: 60ml (0.6-1.0 ml/kg in children) bolus of 10% Calcium Gluconate over 5-10 min. May need to be repeated every 20 mins (Up to 3 doses). Then commence an infusion of Calcium Chloride (1g/hour), suggested optimal serum ionised Calcium 2mmol/L (VBG/ABG monitoring)
  3. High - Dose Insulin Therapy
  • 50ml of 50% Glucose (25g) bolus THEN 1 IU/kg Actrapid (short acting Insulin) bolus
  • Continue Glucose 25g/hr IV infusion & Short Acting Insulin 0.5 IU/kg/hr IV infusion
  • Glucose infusion titrated to maintain euglycaemia
  • Insulin infusion may need to be increased to 1 IU/kg/hr
  • Infusions need to continue until CV instability has resolved

     5. Inotropes: Noradrenaline &/or Adrenaline titration

     6. Na Bicarbonate (50-100 mmol/L (0.5-1.0 mmol/L in children) for metabolic acidosis

     7. Cardiac pacing: Often Difficult Transcutaneously, Transvenously next step

If cardiovascular collapse despite above, consider

  • early invasive intervention and consideration of ECMO / Cardiopulmonary Bypass / Balloon Pump
  • Methylene Blue (controversial and lacking good data but several case studies have shown benefit) 1.5mg/kg loading dose then 1.5mg/kg/hr infusion
  • Lipid emulsion (Intralipid)

Decontamination

  • Consider activated charcoal if presents early
  • Whole bowel irrigation if slow release form ingested
  • Consider charcoal haemoperfusion for verapamil

 

References

Calcium Channel Blocker Toxicity

Is methylene blue beneficial in treating calcium-channel-blocker overdose?

Methylene Blue in the Treatment of Refractory Shock From an Amlodipine Overdose. 

PAEDS ASTHMA, FEBRILE CHILD & A FEW RASHES

Tues 2nd Feb '16

This week we'll be covering:

  1. THE FEBRILE CHILD
  2. ASTHMA ASSESSMENT & MANAGEMENT
  3. RASHES

PLUS A LOOK AT SOME RASHES TO FINISH UP

 








VASCULAR ACCESS

Tues 26th Jan '16

Guest Speaker: CHRIS DAVLANTES

AIM: COVER INTRAOSSEOUS, CENTRAL & USS PERIPHERAL IV ACCESS

 

IO ACCESS

INTRAOSSEOUS NEEDLE INSERTION (LITFL)

EZ-IO (LITFL)

SEIZING & NO ACCESS! (LITFL)

EZ-IO CLINICAL EDUCATION RESOURCE (TELEFLEX)

 

 

A PEARL TO REDUCE PAIN ON INFUSION:  'MARROWNATE' PRIOR TO USE

  • PRIME THE GIVING LINE WITH LIGNOCAINE (CONTAINS UP TO 1ML)

'MARROWNATION'

TELEFLEX VIDEO FOR RECOMMENDED LOCAL ANAESTHETIC TECHNIQUE

(SEE OTHER LINKS IN EDUCATION RESOURCE ABOVE)