NPLEX Combination Review Emergency Medicine

Paul S. Anderson, ND

Medical Board Review Services

Copyright MBRS

Emergency Childbirth

i.e. you would be surprised how common an emergent birth

situation occurs on a board exam!

Signs that birth is imminent:

• Contractions 2-3 minutes apart or less– How is the interval timed?

• Mother feels urge to push with each contraction• Crowning

Preparation

• Get mother comfortable (prop with pillows)

• Drape abdomen, each leg, as well as under her

• Wash hands!

• Get ready for the “catch”

Delivery: Head

Delivery: Shoulders

Head and shoulders rotatenaturally

If possible, clear airway

Delivery: Chest and Rest of Body

Delivery: Catch!

Lay baby NEXT to Mother and:

• Clear Airway• Towel dry and wrap in

dry blanket• If not breathing (crying)

yet, clear airway again, and flick soles of feet

• If still not breathing, give 2 breaths, check pulse and CPR if needed

• EMS

Two most important concerns:

Airway & Breathing

Preventing heat loss

Cutting the cord

• After drying and breathing has started

• Make two ties: 4 inches from baby and 6 inches from baby

• Cut between

Placenta Delivery

• With infant wrapped up and breathing, and cord cut, place on mother’s abdomen

• Let placenta deliver passively!

Three things have to go to hospital:

• Mother

• Baby

• Placenta

Surprises! (Complications)• See pdf file “Pregnancy and Childbirth” from TVI-CC

• Twins• Prematurity

– More prone to airway/breathing problems & heat loss• Breech

– Tush and feet appear first– Footling breech- arm or leg appears first

• True obstetrical emergency

• Nuchal cord – cord around infant’s neck– Slip over baby’s head

• Prolapsed cord – cord comes out first– True obstetrical emergency

Ectopic Pregnancy

• Female of child rearing age

• Sudden onset of belly pain with no obvious cause

• Development of shock

• Treat shock and activate EMS

Basic Life Support

Remember the Basics:

• ABC’s rule all DDX and Tx in emergent conditions!

• For multiple casualty triage:– The dead stay dead.

• If you have a scene with three injured people and one is pulse-less and breathless – they are last priority.

– Remember the ‘scene survey’ – if it is not safe to respond don’t!

CPR• Combines rescue breathing and chest

compressions

• Revives heart (cardio) and lung (pulmonary) functioning– Use when there is no breathing and no pulse

• Provides O2 to the brain until ACLS arrives

How CPR Works

• Effective CPR provides 1/4 to 1/3 normal blood flow

• Rescue breaths contain 16% oxygen (21% - ambient air)

Start CPR Immediately

• Better chance of survival

• Brain damage starts in 4-6 minutes

• Brain damage is certain after 10 minutes without CPR

Do Not Move the Victim Until CPR is Given and Qualified Help

Arrives…

• unless the scene dictates otherwise–threat of fire or explosion

–victim must be on a hard surface

–Place victim level or head slightly lower than body

Even With Successful CPR, Most Won’t Survive Without ACLS

• ACLS (Advanced Cardiac Life Support)

• ACLS includes defibrillation, oxygen, drug therapy

Survey The Scene, then: RAP

• R - Responsiveness –Tap shoulder and

shout “Are you ok?”

RAP

• A - Activate EMS ( if unresponsive)– YOU - call 911 – come back and let me

know what they said (another can stay by the phone)

– You may have to make the call

RAP

• P - Position on back–All body parts rolled over at

the same time• Always be aware of head and spinal cord injuries

• Support neck and spinal column

ABCD

• Airway

• Breathing

• Circulation - Bleeding

• Disability (keep this in mind from the beginning)– If victim is unconscious but does

display vital signs, place on left side

Checking Vital Signs• A – Airway

–Open the airway

–Head tilt chin lift

B – Check For Breathing

• Look, listen and feel for breathing– No longer than

10 seconds seconds

Breathing

• If the victim is not breathing, give two breaths (1 second or longer)– Pinch the nose– Seal the mouth with yours

• If the first two don’t go in, re-tilt and give two more breaths (if breaths still do not go in, suspect choking)

Breathing: Mouth To Nose (when to use)

–Can’t open mouth

–Can’t make a good seal

–Severely injured mouth

–Stomach distension

• Mouth to stoma (tracheotomy)

Compressions

• After giving breaths…

• Locate proper hand position for chest compressions– Place heel of one hand on center of chest

between the nipples OR

Compressions

– Using both hands, give 30 chest compressions• Count 1, 2, 3 …

– Depth of compressions: 1 .5 to 2 inches

– For children: ½ to 1/3 of chest depth and use 1 or 2 hands (keep one hand on forehead if possible)

CPR

• After 30 chest compressions give:

• 2 slow breaths • Continue until help arrives or

victim recovers

• If the victim starts moving: check breathing

When Can I Stop CPR?

• Victim revives• Trained help arrives• Too exhausted to continue• Unsafe scene• Physician directed (do not resuscitate

orders)• Cardiac arrest of longer than 30 minutes

– (controversial)

Two Partner CPR

• Rescuer 1:– RAPAB (in charge of airway pulse and

breathing)

• Rescuer 2:– place hands for compressions

• Compression rate: 30:2

• Switch off when tired

• 1 and 2…..4 and change

Checking for CPR Effectiveness

• Does chest rise and fall with rescue breaths?

• Have a second rescuer check pulse while you give compressions

Why CPR May Fail• Delay in starting• Improper procedures (ex. Forget to

pinch nose)• No ACLS follow-up and delay in

defibrillation– Only 15% who receive CPR live to go

home– Improper techniques

• Terminal disease or unmanageable disease (massive heart attack)

Injuries Related to CPR

• Rib fractures

• Laceration related to the tip of the sternum–Liver, lung, spleen

Complications of CPR

• Vomiting–Aspiration

–Place victim on left side

–Wipe vomit from mouth with fingers wrapped in a cloth

–Reposition and resume CPR

Stomach Distension

• Air in the stomach – Creates pressure against the

lungs• Prevention of Stomach Distension

– Don’t blow too hard– Slow rescue breathing – Re-tilt the head to make sure the airway is

open– Use mouth to nose method

Mouth to Mouth Barrier Devices

• Masks

• Shields

Choking

• The tongue is the most common obstruction in the unconscious victim (head tilt- chin lift)

• Vomit• Foreign body

– Balloons– Foods

• Swelling (allergic reactions/ irritants)• Spasm (water is inhaled suddenly)

How To Recognize Choking

• Can you hear breathing or coughing sounds?– High pitched breathing sounds?

• Is the cough strong or weak?• Can’t speak, breathe or cough• Universal distress signal (clutches

neck)• Turning blue

Recognizing Choking #2

• A partial airway obstruction with poor air exchange should be treated as if it were a complete airway blockage.

• If victim is coughing strongly, do not intervene

Conscious Choking (Adult Foreign Body Airway Obstruction)

• Give 5 abdominal thrusts (Heimlich maneuver)

– Place fist just above the umbilicus (normal size)

– Give 5 upward and inward thrusts– Pregnant or obese? 5 chest thrusts

• Fists on sternum• If unsuccessful, support chest with one

hand and give back blows with the other

• Continue until successful or victim becomes unconscious

If You Are Choking And You Are Alone

• Use fist

• Use corner of furniture

• Be creative

If Victim Becomes Unconscious After Giving

Thrusts

• Call 911• Try to support victim with your

knees while lowering victim to the floor

• Assess• Begin CPR• After chest compressions, check

for object before giving breaths breaths

You Enter An Empty Room And Find An

Unconscious Victim On The Floor

• What do you do?

• Assess the victim (RAPABC)– Give CPR if needed

– After giving compressions:• look for object in throat• then give breaths

CPR for Infants (Under 1 Year of Age)

• Same procedures (RAPAB) except:

• Seal nose and mouth or nose only

• Give shallow “puffs”

CPR: Infants• RAPAB• Give CPR

– Press sternum 1/2 to 1/3 depth of the chest

– Use middle and ring finger

• 30 compressions to 2• If alone, resuscitate for 2

minutes then call 911

Choking: Conscious Infants

• Position with head downward

• 5 back blows (check for expelled object)

• 5 chest thrusts (check for expelled object)

• Repeat

Choking: Unconscious Infants

• If infant becomes unconscious:• RAPAB• When the first breaths don’t go in, check for

object in throat then try 2 more breaths.• If neither set of breaths goes in, suspect

choking• Begin 30 compressions• Check for object in throat (no blind finger

sweep)• Give 2 breaths

Guidelines for Dealing with Children

• Get parental consent (implied in emergency)

• Involve the parent(s)?

• Talk TO child

• Try to be close to eye level

• Don’t lie or surprise!

Child Abuse: Treat and Notify Police or County Protective Services

• Wounds in different stages of healing

• Wounds that suggest defensive posturing– Hands and forearms– Back, back of head,back of legs

• “Unusual” explanation

Injection Therapies

Peripheral Injections

Peripheral Injection Complications

– Abscess: Post injection infection. Contaminated infusate or “dirty” stick. Antibiotic Tx, Heat, and I&D are possible.

– Broken needle: Why you don’t bury the needle to the hub. Prevent by pre inspection, and not flexing the needle during use.

– Hematoma: Leaky veins post injection. Use post injection direct pressure to slow this down. Watch anticoagulant patients.

– Post treatment pain: Typically from tissue fullness.Movement, Ice, or alternating hot and cold help.

– Shock / Syncope: Remember, this may be vaso-vagal effect or may be actually due to some component of the injection.

• Glycemic emergency?: Consider this in those with prior blood sugar problems, as well as high dose Vitamin-C (Hypoglycemic reaction) and Corticosteroid Hyperglycemic reactions) injections.

– Anaphylaxis: Always possible. If unsure about a medicine, either do not use it, run an interdermal test on it, or premedicate the patient to negate the IgE effects. (See below for treatment)

Injection Procedures - 1• Injectate

– Inspect vial for particles / film / cracks etc…– Check expiration date– Clean stopper with alcohol

• Syringe / Needle– Ample size for total injectate volume– Draw with large bore needle

• Ideally, drawing needle should be different from injecting needle• Draw with 21 – 18 gauge for fastest draw (some solutions are thicker

than others). Also Filtered needles and “NoCor” needles available.• Exceptions are small volume single medicine injections

(B12/Insulin…)

• Drawing up injectate– Wash hands– Insert needle into vial– Inject air to equal volume to be withdrawn (except in DMPS vials)– Draw prescribed volume into syringe– Remove needle from vial / one handed “soft” re-cap or hemostat change

Injection Procedures - 2• IM Sites

– Deltoid• Adults and some children over 2

– Vastus lateralis (Thigh)• Preferred for children under 2

– Gluteus maximus (Hip)• In adults, larger muscle for larger quantities or thicker solution

• IM procedure– Wash hands / Glove up / Prep patients skin– Place injecting needle on syringe / Remove cap from needle– Stabilize patient skin with one hand and hold the syringe like a dart or a

pencil with the other– Enter skin quickly at a 90 degree angle / Stop ½ to 1 cm prior to hub of

needle– Aspirate** / Inject material slowly, then withdraw the needle– Cotton ball to injection site / Dispose of syringe in sharps / Bandage

patient

Subcutaneous injection:

Subcutaneous injection-2•In addition to other injection procedures you already know:

•Pinch up a quantity of skin

•Inject into the elevated area (SQ) at @30 degrees

Intradermal Injection:Injection siteThe usual choice of site is the anterior forearm. However,

the upper chest, upper arm or shoulder can also be used.Administration of drug or antigen1. Wash and dry visibly soiled skin. 2. Hold the middle of the patient's forearm in your non-

dominant hand, anterior side up. 3. Pull the anterior skin taut with your thumb and forefinger. 4. Insert the needle under the outer layer of the skin at an

angle of 10-15°. 5. Slowly administer injection, observing for wheal

formation to show medication has entered the dermis. 6. Withdraw needle and wipe skin gently. Do not rub or

apply pressure as this may disperse the medication into surrounding tissue.

IV Therapy

Solution Guidelines: IV Admixtures

Due to potential for phlebitis / vein injury, the following guidelines are common for IV admixtures delivered through peripheral (NOT Central) IV placement:

• pH: “5-9” (Human blood is pH 7.35-7.45)– Acidic range: OK to 5 pH or higher

– Alkaline range: Do not exceed 9 pH

– Patient comfort max at 6.6 – 7.6

Solution Guidelines: IV Admixtures• Osmolarity:

– 150-450: Low risk of phlebitis– 450-600: Moderate risk of phlebitis– 600 + : 100% risk of some phlebitis (Gazitua, et al)

** Remember: changing osmolarity (dilution) does not change pH. Both need to be assessed.

** Changes that can be made include:

– Slow the IV– Increased solution (dilution)– Buffering additions (Bicarbonate or HCl)– Using the largest vein available– Watching catheter tip placement

IV – Local Complications– Hematoma:

• Fragile veins, elderly pt., poor technique.• Use small gauge device (catheter whenever possible)

• Educate high risk patients

• Pressure bandage

– Thrombosis: • Clot due to endothelial trauma. • Technique can play a role (Vein damage). • Watch for slow / stopped flow rate. • D/C the line, apply ice / pressure. • This is rare in short term infusions.

IV – Local Complications– Phlebitis: Common.

• Osmolarity, flow rate, catheter size and placement all play a role. Redness / swelling of the vein.

– Vein may stay “ropy” for some time after (10 – 40 days). – Vein may sclerose.

• 4 Grades of phlebitis• • Use large vein for hypertonic solutions

» (ie. not the hand)• Buffer solutions• Tx.: Prevention, Flush with NS, D/C line, apply ice.

– Thrombophlebitis: • Phlebitis with thrombosis. • Same causes. • More rare in short infusions. • Treatment is the same as for both.

IV – Local Complications

– Infiltration / Extravasation: • Fluid flowing into the subcutaneous tissues. • Area becomes swollen, cool, and typically

painful. • Flow rate slows.• STOP infusing and gain access!• Light pressure, Ice, Apis (hp)

– Local infection: Same as abscess formation above.

IV – Local Complications– Venous spasm:

• Smooth muscle in vein wall / autonomic nervous system create spasm.

• May be due to irritating / hyperosmotic pH unbalanced or COLD solutions.

• Pain at site that travels up the arm. • Slow flow, warm solution, flush line, check (RECHECK) pH, heat on

arm, check arm position.

– Hypersensitivity reactions: Allergic reaction to solution components. See below.

– LINE FLUSHING PROTOCOLS: • Saline:

– Slow flush through port with flow of IV stopped. – No smaller than 10 cc syringe!!

• Procaine / Lidocaine: – 1 or 2% drug (1cc.) in 9 cc NS. – SLOW push!!!!

IV – Systemic Complications– Septicemia:

• Systemic infection. • BAD! • Contaminated solution / equipment etc. • OBTAIN BLOOD CULTURES!• Toxic patient, fever / malaise / N-V-D / etc.• Tx with Immune support, ABX etc.

– Fluid overload: • Infusing an ISOTONIC solution too quickly. • Watch the elderly and those with compromised kidney function. • Edema, Hypertension, Pulmonary edema (SOB & Crackles)• Tx:

– Slow fluid infusion – Heat to dilate peripheral circulation– O2 administration

IV – Systemic Complications– Pulmonary edema:

• Typically in those with CVD or Renal Dz. • Fluid overload causes Left heart inability to remove fluid

from the lungs. • Tx is same as fluid overload.

– Air embolism: • Air infusion that collects in the right side of the heart.

Typically associated with electric pumps. – “MILL WHEEL MURMUR” may be present. – Respiratory, affective, and neurological findings

• It takes 10 to 60 cc of air to kill a human.• If air gets to the right ventricle and up to the

Pulmonic valve it will occlude flow to the lungs.• Tx: LEFT LATERAL DECUBITUS POSITION! O2.

Monitor vitals. EMS transport to ER.

IV – Systemic Complications– Speed shock:

• Rapid administration of a Medication / Vitamin or Mineral that causes a sudden rise in the plasma concentration of the substance.

– i.e. Magnesium pushed too fast causes BP to drop…

• Dilution, slow pushes, and patient interaction are the best prevention.

– Catheter embolism: • Shearing off of the end of the catheter.

– It will travel through the venous system and embolize.

• Save the rest of the catheter. • Digital pressure proximal from the site / and-or tourniquet application.

• Radiological exam / ER visit needed.

• NOT advancing and retracting the catheter over the needle (even prior to insertion) prior to removal of the needle is key!

IV – Systemic Complications– Electrolyte (Macro-mineral) Shift:

• Administration of Ca / K / Mg individually typically can predispose a patient to a “hyper” state.

– Patient may show muscle cramping signs, or signs of hyperkalemia.

• Mg. And Ca. “push” syringes should be kept as antidote• May be a side effect of chelation therapy (See

chelation notes)

– Glycemic emergency: • Have patients eat during high Vitamin C infusions and

EDTA chelation. • D5W infusion, or slow push of D50 (5cc D50 in 5 cc

sterile water) will reverse.

Emergency Protocols• Assess

– ABC’s• Airway• Breathing• Circulation

– Etiology: • Speed shock / Hypersensitivity…• What do you really need to treat?

– EMS or not: Your call. You are the Dr. in charge.

Emergency Protocols• Respond

– First assure ABC’s stable

– Response based on supposed etiology• Syncope

• Speed Shock

• Glycemic emergency

• Anaphylaxis

• MI

• Other

Emergency: Syncope• Patient in Trendelenberg position

– NOTE: Some hospitals no longer include in their standard protocols.

• DO NOT D/C THE I.V. LINE!!!

• Slow (stop) infusion rate

• Talk to them (if conscious)

• Have them move their feet

Emergency: Syncope

• Smelling salts if unconscious

• Cover with blanket

• Watch for “re-entry” seizure activity

• Reassure them and others present

• Continue infusion if warranted

Emergency: Speed Shock• Trendelenberg position in some cases

• STOP the infusion – do not D/C the line!

– Infuse NS

• Treat acute symptoms of the overdose

• Administer antidote if necessary

Fluid overload:

• Infusing an ISOTONIC solution too quickly.

• Watch the elderly and those with compromised kidney function.

• Edema, Hypertension, Pulmonary edema (SOB & Crackles)

• Tx: – Slow fluid infusion – Heat to dilate peripheral circulation– O2 administration

IV Fluid DynamicsIsotonic Hypotonic Hypertonic

Effect on intravascular compartment

(blood)

Increases volume

Dehydrates – moves

fluid to cells

Greatly increases volume –

dehydrates cells

Fluid overload potential

Incr. in Ki / Li patients, and

the elderly

Moderate potential

[ D5W]

No High potential

D5W (without other additives) starts Isotonic but can act hypotonic if the patient metabolizes the sugar quickly.

Glycemic Emergency• Hyper:

– Ie. Steroid injection / D5 – D50 too fast– Watch and wait if appropriate with patient

recumbent– Administer NS or ½ NS– Insulin (SQ or IV) if appropriate

• Hypo:– Prevention

• Watch High dose Vitamin C, EDTA…

– D5W administration or “50/50 mix” D50 & Water• Administer IV in a D5 base if patient is a recurrent reactor

Emergency: AnaphylaxisSee also emergency handout.

• Initial Sn / Sx:– Apprehension / urticaria / edema / throat sensation– Severe cases:

• Hypotension• LOC • Mydriasis • Incontinence • Convulsion • Sudden Death

• STOP the infusion but DO NOT D/C THE LINE!!!– Change Bag and Line to NS infusion and run in

Emergency: Anaphylaxis• Patient in Trendelenberg position

• Assess ABC’s– Airway must be patent – insert airway if

needed• If patient not breathing, administer ‘Ambu’ or

Rescue breaths

– Assess peripheral (emergency) blood pressure

• Radial pulse = AT LEAST 80 Systolic• Femoral pulse = AT LEAST 70 Systolic• Carotid pulse = AT LEAST 60 Systolic

Emergency: Anaphylaxis• Treat:

– BENEDRYL: 50 mg (1ml) IV stat• Note: this is not normally done before Epi.

– Epinephrine: KNOW THE CONCENTRATION!!!!!!• 1:1000 is IM / SQ and Intratrachial ONLY!!

– Use 0.3 to 1 cc IM / SQ Immediately if this is the type you have

• 1:10,000 is the IV form– IV administer 3 cc and wait. May give all 10 cc.

– Oxygen High Concentration (~15 L / min) by mask. (3 L / min in COPD)

Emergency: Anaphylaxis• Steroids – Stabilize cytokine storm:

– Dexamethasone @ 10-20 mg (2.5 to 5 cc)– Solu-Cortef (Hydrocortisone) @ 100 – 500 mg– Solu-Medrol (Prednisone) @ 30-60 mg

• Calcium Gluconate - To reverse hypocalcemia: – up to 10 ml (1G) / 2 min X3 then 1G in 500 ml NS

• Magnesium Sulfate – For spasm or Calcium overdose: 1G / 1-2 min. then

5G in 250 –500 NS

• Albuterol / Aminophylline: – Limited help / use if you have.

Osmolarity• Osmolarity: The concentration of solute

in a volume of solution

• Osmolarity of human body fluids– 280-295 mOsm/L (Average 290)

• Tonicity of solutions infused– Isotonic: 250 – 375 mOsm/L– Hypotonic: Below 250 mOsm/ml– Hypertonic: Above 375 mOsm/L

Osmolarity – Solution Dynamics• Isotonic:

– 250 – 375 mOsm/L• Normal Saline (0.9% Sodium Chloride / NS)• 5% Dextrose in Water (D5W)• Ringer’s Lactate (Balanced electrolyte

solution)

– Do not cause fluid shifts (between compartments) so they may cause circulatory overload (over expanded vascular compartment and dilution of the cellular component of the blood)

Osmolarity – Solution Dynamics• Hypotonic:

– Below 250 mOsm/L• 0.45% Sodium Chloride (1/2 NS)

– Lowers plasma osmolarity, so fluid leaves blood compartment and goes to cellular compartment.• Hydrates cells / Lowers serum Sodium• Can cause hypotension

Osmolarity – Solution Dynamics• Hypertonic:

– Above 375 mOsm/L• D10 and D20 infusions• Most vitamin / Mineral infusions given (May be 500 to

2000 + mOsm/L)

– Shift fluid into the plasma compartment – can cause circulatory overload

– IRRITATING TO THE VEIN WALLS – MAY BE PAINFUL

• Give at slow rate: 1 to 5 ml/min.

Osmolarity - Calculation• {[(Volume) X (mOsm/ml)] / (Volume)} X 1000

• Example:Component: Volume, ml mOsm/ml (Volume X mOsm/ml)

Ascorbic acid, 500 mg/ml 150 5.80 870.0

Sodium Bicarbonate, 8.4% 10 2.00 20.0

Sterile Water for injection 250 0.00 0.0

==================================================================

Totals 410 ////////// 890.0

==================================================================

Solution Osmolarity = {[890.0] / 410.0} X 1000 = 2170.73

• So this would be a very hyperosmolar solution…

Base IV Solutions - 1• Dextrose in Water

– D5W: 5% Dextrose in Water. ISOTONIC. 1.5 to 2 liters / day average.

• Good for mixing solutions in. Used in cancer therapies.

– D10/20/50: Lowers Potassium. HYPERTONIC. Glucose support.

• Sodium Chloride– 0.45% HYPOTONIC– 0.9% ISOTONIC– 3% / 5% HYPERTONIC

Base IV Solutions - 2• Dextrose and Sodium Chloride

– D5 and 0.9%NaCl • ISOTONIC

– 2.5 % or 5% Dextrose and 0.2% or 0.45 % NaCl • HYPERTONIC

• Sterile Water (HYPOTONIC) Good for mixing high osmolarity solutions.– NEVER infuse alone. RBC Lysis results.

• Electrolyte Solutions (ISOTONIC) *Check for incompatibilities with additives.– Ringer’s: Electrolyte replenisher. For dehydration.– Ringer’s Lactate: “Hartmann’s solution”. Very similar to the

ECF electrolytes.• Do not use in Addison’s or liver disease where lactate metabolism is

impaired.

Chelation Issues

Chelation: Cautions and contraindications

Medications: Calcium channel blockers and EDTA will

have additive cardiac blockade effects. (Ca-EDTA less so than Na-EDTA – but both

are a concern)

Magnesium also has added Ca-Blockade. Use with caution, and titrate the dose

slowly in patients on Ca-Blocking meds.

Chelation: Cautions and contraindications

• Renal insufficiency– Mild to Moderate: Lower dose, and treat no more than once weekly.– Severe: Contraindicated.

• Liver disease– Monitor closely in patients with mild to moderate Liver enzyme elevation– Severe Liver disease is a contraindication.– Active Hepatitis B&C are relative contraindications.

• Anticoagulation– Pro-times must be monitored closely as EDTA may change clotting time.

• Congestive heart failure– All cardiac parameters must be monitored closely. Baseline EKG etc.– Calcium levels should be assessed every four weeks

• Pregnancy– Contraindicated

Airway ManagementAnaphylaxis

Shock

Croup – inflammation of the larynx, trachea, and bronchi

• Usually between 3 months and 3 years– Usually while asleep

• Complication of viral infection• Difficulty breathing• Crowing sound on inspiration

(inspiratory stridor)• Seal-like barking cough• Breath cool moist air for 5

minutes– If no improvement after 5

minutes continue to monitor– If condition worsens transport

to hospital

Epiglottitis

• Usually between 3 –10 years• Caused by H. influenza (or

occasionally a beta hemolytic Strep) infection

• High fever / Toxic Child• Difficulty breathing• Inspiratory stridor• Drooling• Try moist air breathing• Will need antibiotics and

Airway management!– Do not move neck or open

mouth– EMS Transport to ER

Acute Airway ; Anaphylaxis

• Signs of Allergic Reaction– Strange sensations in patient– Affected respiration (laryngeal edema)– Edema, errythema, allergic dermatitis

• Treatment– Epinephrine

• IM- 0.5-1.0 mg/ml (1:1,000), Subcutaneous- 0.3-0.5 ml• IV push-0.1-0.2mg (1-2 ml) (1:10,000)• Can repeat Q 3-5 min

– Diphenhydramine• 25-50mg IM or IV push

Oxygen Delivery Systems

Nasal Cannula– Easiest to wear, on demand or continuous– Lowest flow rates-up to 6 lpm=20-40% O2

• Simple Mask– 6-10 lpm gives approximately 40-60% O2

• Partial/Non Rebreather Mask– Partial has air release valves, NRB-one way valve only– For liter flows 60-100% O2– Usually used in Acute Emergency situations

• Venturi Mask– Used if specific flow is needed– Valves for 25-50% O2

• Ambu Bag/Mask– For Emergency situations requiring manual ventilation of

pt

Upper Airway Obstruction

• All Patient presentations include inspiratory and/or expiratory Stridor (high pitched sounds)

• Possible retractions of the thorax– Intercostal, suprasternal, supraclavicular

• Cyanosis (later stage)• Drooling (common in pediatrics)• LOC with full obstruction

Upper Airway Obstruction:Tx

• Determine if obstruction is mechanical or infectious!

• If mechanical; Do Heimlich procedure• If infectious; consider Epiglottitis

– Usually found in pediatrics– Sudden onset– Pt can’t swallow properly/Drooling common– Tripod position– Swollen airway, infectious signs of

fever/malaise

What is Shock?

• The state of metabolic failure that may be caused by either inadequate delivery of oxygen to the tissues or improper metabolism of oxygen at the tissue site

• Types– Early (compensated) reversible in nature

• General sympathetic nervous system reaction to causative factors, body is compensating

– Late (decompensated) difficult to reverse effects• System is unable to maintain sympathetic responses to

causative effects, starts to decompensate and go into failure mode

Shock Severity Determinants

• Compensated Shock– Mechanism– Signs/symptoms

• Tachycardia, anxiety, restlessness, apprehension, delayed capillary refill, diaphoresis, widened pulse pressure

– Treatments are preventative in nature with ABC interventions

• Decompensated Shock– Mechanism– Signs/symptoms

• Hypotension, confusion, Loss of consciousness, oliguria, acidemia

– Treatments is aggressive and rapid volume resuscitation, medications and invasive procedures

Signs of Shock

• Tachycardia– Earliest signs of shock

• Hypotension– Late sign of shock

• Adrenergic responses– Restless, agitated– cool clammy skin– “livedo reticularis”-mottled skin

• Altered Mental Status• Orthostatic Vital Signs

– Problems occur in standing position, often resolve supine

Classification of Shock

• Hypovolemic Shock– Due to a loss of fluids

• Cardiogenic Shock– Cardiac obstruction or pump failure, MI

• Obstructive Shock– Significant fall in cardiac output, CHF

• Distributive Shock– Loss of intravascular and decreased vascular volume;

Neurogenic, sepsis, infectious problem

• Glasgow Coma Scale– Eye opening

• Spontaneous 4

• To verbal command 3• To pain 2• None 1

– Verbal Responsiveness• Orientated 5• Confused 4• Inappropriate words 3• Incomprehensible 2• None 1

– Motor Response• Obeys commands 6• Localizes pain 5• Withdraws 4• Flexion 3• Extension 2• None 1

• Revised Trauma Score– Respiratory rate (breaths

per min)• 10-29 4• >29 3• 6-9 2• 1-5 1

– Systolic BP (mmHg)• >89 4• 76-89 3• 50-75 2• 1-49 1• No pulse 0

– Glasgow conversion scale• 13-15 4• 9-12 3• 6-8 2• 4-5 1• < 0

Seizure

• Remember:

– Epilepsy is a clinical diagnosis of exclusion to be sure that the seizure is not from:

• Infection• Mass / CA• Electrolyte imbalance• Etc…

Seizures (Tonic-Clonic)

• Most common are febrile

• Toxin ingestion

• Treat as any seizure and get follow up medical care– Protect patient during seizure to the degree

possible– See Neuro Notes for other DDX with seizure.

Head Injuries and Trauma

• Head Injuries– All patients with head injuries and trauma should be

treated as if they are positive for cervical spinal injury• C-spine immobilization• Cervical Collar• Head blocks• Long board

– Treat with ABC’s, Glasgow Coma Scoring and Neurological exam techniques

– All head injury patients require 100% O2 therapy• Conscious pts with adequate respirations-Non-rebreather• Unconscious or impaired respirations-Bag valve mask

Head Injury-special considerations

• Associated Symptoms– Seizures

• Considered in GCS <8, cerebral contusion, depressed skull fracture, intracranial hematoma, penetrating head wound

– Combativeness• Evaluate for hypoxia, hypoglycemia, hypotension and pain

– Pain Control• Sedatives-analgesics (narcotics, benzodiazepines)

– Systemic Hypertension• Signs of Intracranial Pressures

– Bradycardia & hypertension

Neck and Spinal Trauma• Airway management• Cervical stabilization• Penetrating wounds

– “Leave it there”-knife, sharp objects– Underlying anatomical areas– Nerve involvement (test cranial)

• Whiplash Injuries (cervical strain)– Hyperextension injury most common– No associated fractures– X-ray is diagnostic– 12-24 hrs for manifestation of symptoms

Trauma and Bleeding

• Primary Survey/Circulation– Establish Homeostasis

• Assess any obvious hemorrhage• Apply indirect homeostasis measures

– Apply pressure to wound» Graded pressure with pressure bandages

– Elevate injury above level of heart– Vaso-constrictive measures

» Not more than 30mm Hg (blood pressure cuff)

Wound Assessment

• Detailed wound info– Time of occurrence

• Reduced bacteria in first 6 hours (closure)• Increased blood supply lengthens exposure time

(facial wounds up to 24 hrs)

– Exposure of wound• Possible environmental contaminants

– Mechanism of injury• Instrument of injury• Fragmental mechanisms• Chemical exposure

– Cold can extend tissue integrity

Types of Wounds

• Lacerations– Minimal tissue injury– Reduced risk of infection

• Puncture– High risk of infection– Check for foreign bodies

• Stretch Injuries– Damage to blood vessels,

nerves, ligaments, tendons– Damage may not be visual

on inspection

• Crush/Compression– Highest level of tissue

necrosis– Hemorrhage risk– Difficult for tissue to heal

due to trauma

• Bites– Highest risk of infection– Often requires delayed

closure of wound to allow drainage

– Irrigation necessary

Wound Management

• Wound closure– Contra-indications to closure

• Heavy bacterial infection– Needs irrigation, antibiotic therapy

• Major tissue defects– Debridement of dead tissue– Excessive tension on wound

• Foreign body• Devitalized tissue

– Primary Closure• Suture or butterfly adhesive suture closure

– Secondary Closure• Wound heals from inside• No primary closure done due to infection risk

Wound Management• Wound Risk Assessment

– Infection• Puncture, crush injuries• Environmental risks• Tetanus

– Usually deep puncture with soil exposure– Wash wound with antibacterial soap immediately– Immunization hx Q 10 yrs, shots if exposure risk is high

• Rabies– Consider rabies immune globulin USP

– Healing Processes• Thickening around wound x 3 months• Errythema around scar x 3-6 months• Keloid or hypertrophic scar formation risk• Acupuncture around scar post healing

– “Surround the dragon” technique

Burn Injury Assessment• Severity of Injury

– Burn Size• Rule of Nines (adults)=100

– 9=each arm, head/neck– 18=each side of torso, each leg– Genitalia and perineum=1

• Rule of Fives (pediatrics)=100– 10=each arm, and infant leg– 15=head/neck of child and each leg– 20=infant head/neck, child side of torso– No value for peds genitalia

Rule of Nines/Fives   

Burn Assessment• Burn Depth

– Superficial (1st degree)• Mild errythema, heals spontaneously

– Partial thickness (2nd degree)• Heals spontaneously• Blistering, errythema• Deep Partial Thickness burns might

need grafting to decrease contractures and hypertrophic scarring

– Full-thickness (3rd degree)• Deep past skin layers• Damage to nerves, vessels• Loss of sensation common• Needs grafting

Burn Assessment• Major Burn Injuries

– 2nd degree >25% BSA (adults)– 2nd degree >20% BSA (peds)– 3rd degree >10% BSA– Most burns of face, hands, eyes, ears, feet,

perineum– Inhalation, Electrical, major trauma– Poor risk patients (adults >55yrs , peds< 5yrs)

• Moderate Uncomplicated Burn Injury– 2nd degree 15-25% BSA adults– 2nd degree 10-20% BSA peds– 3rd degree <10% BSA

Burn Assessment• Location of Burns

– Hands and Feet• Can cause scarring and disability

– Face• Associated with inhalation injury• Physical/emotional injury

– Eyes• Corneal scarring• Quick assess-periorbital edema is eminent

– Ears• Pressure deformity• Infection risk

– Perineum• High risk of infection

Burn Assessment• Types of Burns

– Circumferential• Considered major injury• Lymphatic/venous obstruction• Increased tissue pressure/edema• Look at structures affected in area

– Inhalation• Confined spaces• Soot around nares• Stridor, hoarseness, respiratory distress• Carboxyhemoglobin level >10%• Consider Intubation quickly

Burn AssessmentElectrical Burns

• Types– Lightning Burns

» Linear, Punctate, Feathering, Thermal

– Electrical Shock» Alternating house current is

most dangerous» Extensive internal

injury/damage

• Labs-Myloglobinuria present (tissue breakdown)

– Renal damage

• Associated Injury-Fractures Hemorrhage, Internal injuries

Burn Assessment• Chemical Burns

– Determine type of chemical exposure– Take personal precautions for exposure

• Face mask• gloves

– Remove chemical if possible• Powder-brush off• Liquid-see poisoning chart

– Remove associated clothing if smoldering or exposed to chemical

– Consider inhalation injury (treat airway)– Treat wound appropriately to protect skin

integrity and underlying structures

Burn Treatment– Ventilation and Oxygenation

• Non-rebreather, 100%-15 lpm or Bag Valve mask if impeded respiration

• If inhalation injury suspected, consider intubation to protect airway

– Intravenous Access• Necessary in patients with 15% or more body

surface area burns– Due to cellular fluid loss

• At least one large bore IV (>16 gauge)• Insert thru non-burned skin• Central venous access used for large burns

Fluid Resuscitation– Fluid Resuscitation

• Large losses of fluids, electrolytes and proteins thru increased capillary permeability

• Maximum loss during first 6-8 hrs• One half of fluid volume given in the first 8 hrs,

the remainder over next 16 hrs

– Types of Resuscitation• Parkland (Baxter)Lactated Ringers 4 ml/kg per bsa

burned adults

• Modified Brooke Lactated Ringers 2 ml/kg per bsa burned adults, 3 ml/kg per bsa pediatrics

Burn Treatment

• Laboratory Data– CBC, carboxyhemoglobin levels, CMP, urine

electrolytes, ABG

• Nasogastric Tube– Prevention of aspiration/emesis– Common problems with >20% BSA burns

• Urinary Catheter– Used to monitor urine output as it relates to fluid

resuscitation– Urine output show be maintained at

0.5-1.0mL/kg/h adults, 1.0 mL/kg/h peds <10kg

Urinary Catheter• Equipment• Prepared Foley insertion tray

– Foley catheter (rubber)• 14-18 French catheter (double walled

lumen) with a 5 ml balloon– Urine drain bag– Sterile lubricant– Sterile syringe (5-10ml NS)

• Placement Procedure– Thoroughly cleanse area– Lubricate catheter and insert till urine is

visualized in tube– Advance another 4-5 cm past urine

return for balloon placement, full in men– Inflate balloon with sterile H2O and

attach bag-tape tube to medial thigh for security

Eye Trauma!

Trauma Cascade

In addition to obvious signs and effects of globe trauma, remember the potential for orbital and skull fractures and trauma and

damage to the optic nerve.

http://www.uniteforsight.org/eyesafety/image/blunttrauma3.jpg

Hyphema

Subconjunctival

Hyperemia

Eye Injuries• Chemical burn:

– Irrigation and EMERGENCY referral*****Irrigation as primary intervention– Ointment type instillation prior to transport

• Lacrilube (OTC) / Vitamin A Oil

• “Flash” burn:– Common with people doing welding

– Shredded raw potato poultice

– Vitamin A oil eye application

– Hydro:• Direct cold X 10 min

Eye Injury / Abrasion Corneal Abrasion: • Anesthetize/gross examination with Flourescein dye. May use anesthetic.

– Injury is generally superficial, and dye shows shallow pooling• A patch is worn for 24 hours to maintain lid closure unless injury is <1 mm. • Antibiotics may be needed. Lubricant daily or at least HS during the healing phase. • PO Analgesics for pain, including narcotics.  • *MUST rule out retention of foreign body or matter in the eye before sending patient home (in

most cases irrigation and careful examination will confirm)

Naturopathic treatments:• Lubricant: (see above)

• Botanicals:1.     Calendula succus: (1:1) Apply to gauze. Use as a compress2.      Pleo-muc eye drops3.      Analgesic formula: for eye pain (internal) Piscidia erythina 2 dr (Contraindicated in pregnancy) Passiflora 2 dr Valerian 2 dr Bryonia 5 gtt Gelsemium 30 gtt QSAD: 2 oz SIG: 1 tsp., prn or up to q 2 hr.

• Homeopathy – See Eye – injuries1. Aconite 2. Hypericum 3.Symphytum

Corneal Abrasions:

1: Non-flourescein view

Note lateral corneal edema

2: Flourescein view of another abrasion.

2

Eye Injury / Ulceration

• Injury deeper than the outer (epithelial) corneal layer.

• In general needs referral for work-up

• Concerns include:– Deep infection in the cornea– Scarring / Opacity / Blindness– Perforation

• ND Tx can follow abrasion tx guidelines

• Pain management is very important in ulceration, along with the above.

Corneal UlcerationFlourescein Stain Photography

Mild and Severe

ENT Emergencies

Special Considerations

• Common in school age population

• Can be life-threatening

• May cause great anxiety

• Usually non-urgent

Selected ENT Emergencies

Ear• Laceration• Hematoma• Abrasions• Foreign Body• Burns• Frostbite

Nose• Nasal fracture• Epistaxis• Foreign Body• Acute Sinusitis

Throat• Tonsillitis• Streptococus infection• Peritonsillar abscess• Epiglottis• Retropharyngeal abscess

Interventions In Ear Emergencies

• Lacerations/avulsions– Pad between scalp and

ear– Assess for tetanus status

• Hematomas– Refer for possible

aspiration

• Abrasions– Clean the area– Assess for tetanus status

• Foreign bodies– Attempt to remove if near

external meatus– Avoid excessive

manipulation

• Burns– Wrap lightly in gauze– Pad between scalp and

ear

• Frostbite– Rewarm in warm water– Avoid excessive heat

Interventions In Nose Emergencies

• Nasal fracture– Check for related injuries (e.g. head injury)– Ice– Refer to ED

• Epistaxis– Firm pressure for 10-15 minutes– Refer if bleeding continues or frequent epistaxis

• Foreign body– Have student blow nose vigorously– Remove only if easily retrievable

Interventions in Throat Emergencies

• Tonsillitis/Streptococcus infection– Tx as appropriate

• Peritonsillar abcess/cellulitis– Severe pain, dysphagia– Urgent - refer to ED for treatment

• Epiglottitis - emergent!!– Monitor ABC’s and call EMS

• Retropharyngeal abscess - emergent!!– Monitor ABC’s and call EMS

Prevention• Ear protection from loud noises

• Isolation of infected students

• Protective padding and helmets for sports

– Correct size and fit

– Educate students in proper use

Dental Emergencies

Assessment Of Dental/Oral Trauma

• Use body substance isolation precautions

• ABC’s

• Types include:

– Soft tissue

– Impaled objects

– Injury to tooth

– Injury to bony structures

Soft Tissue Trauma

• Laceration/Bleeding– Apply direct pressure and ice– If major bleed (over 5 minutes) – Tx or Transport

• Edema– If swelling related to trauma - apply ice– Airway compromise, difficulty talking – call EMS

• Impaled Object– Emergent-call EMS– Apply cold packs– Pack gauze sponges around object to secure it

Dental Trauma• Fracture of a tooth

– Small, cover with dental wax– Large, emergent-refer to dentist

• Displacement of tooth– Refer to dentist

• Avulsion of tooth– Replace if possible– Store appropriately for transport with student to

dentist

– Send to dentist within the hour

Bony Fractures

• Alveolar Fracture

• LeForte (Maxillary) Fracture

• Mandible fracture

• Fracture of the zygomatic arch

Bony Fracture Interventions

• Assess ABC's• Check for abnormal movement

– Teeth – Upper or lower jaw

• Ice and direct pressure for bleeding• Emergent - call EMS!• For mandible fracture, stabilize jaw by wrapping a

cravat around the protuberance of chin and top of head

• Transport to ED

Dental Pain

• Caries

• Exfoliation

• Eruption

• Orthodontic appliances

Soft Tissue Pain• Types

– Bleeding gums– Fistula and edema– Ulcers

• Most are non-urgent• URGENT CONDITIONS

– Fistula or swelling• Non-draining• Risk of airway compromise from cellulitis

– Diffuse ulcers• Fever and malaise• Refer for diagnosis and cause

Psychosocial Pain• Dysmorphism

– Facial disfigurement– Craniofacial abnormalities

• Urgent• May be subjected to peer teasing or harassment• Refer to craniofacial team

• Oral Habits– Thumb/finger sucking

• Non-urgent• May result in malocclusion as well as social ridicule• Refer to dentist

PREVENTION

Protective devices are recommended for sport and recreational activities to decrease/prevent the risk of injuries

• Total head and larynx protection – football, hockey, lacrosse, baseball catchers, batters

• Full face protection – fencing, hockey goalies• Eye protectors – all racquet sports, soccer,

basketball, softball

SUMMARY

Pain or injury involving the eyes, ears, nose, throat or oral structures often evokes tremendous anxiety in students. Always maintain a reassuring demeanor as you perform your assessment and management.

Develop and conduct injury prevention programs and implement safety measures to prevent EENT emergencies.