ACLS 2010 - Bradycardias

This video goes over the algorithm for bradycardias. I love the fact that they really simplified everything quite a bit. I'm not as sleepy in this video... no, I actually am.

ACLS 2010 - Cardiac Arrest

Here are the 2010 ACLS Guidelines for Cardiac Arrest. This catch-all category encompasses anything without a pulse, but what had previously been separated out into the separate rhythms of ventricular fibrillation, pulseless ventricular tachycardia, asystole and pulseless electrical activity. I love the fact that they simplified this into one algorithm - and they stress:

• early, deep and uninterrupted chest compressions, and
• early defibrillation (when indicated - VF/VT)

The first video covers the algorithm and drugs

The second video goes into more details about these drugs

The third video looks at PEA and asystole

Case of the Week: 'My Inhaler... Not Working'

Chief Complaint: "My inhalers.... not working"

HPI:
52 year old man presenting via CFD wtih acute onset of shortness of breath.  Per CFD patient was sitting on the edge of his couch holding his inhaler with moderate respiratory distress.  En route he was given 2 treatments of nebulized bronchodilators without much improvement in symptoms.  The patient is refusing to lay on cart sitting on edge of cart, anxious appearing with only one word answers to questions.

From a brief review of electronic medical record you see:

Past Medical History: HTN, asthma (moderate persistent)
Medications: Combivent MDI, Singulair, Lisinopril, HCTZ
Allergies: NKDA
Social History: 20 pack year smoking history - continues to smoke 1/2 pack per day
Vital Signs:

T 99.2F        HR 100       BP 154/92           RR 40          SaO2 88% on 2L via NC
Gen: middle aged man in moderate respiratory distress
HEENT: clear op otherwise unremarkable
Neck: habitus limits jvd assessment, no visible jvd
Pulm: exp wheezing diffusely, no rales, intercostal retractions and tracheal tug noted
CV: tachycardic, reg rhythm, no murmurs, normal s1/s2, no rubs
Abd: soft, nd, nt, +bs
Extrem: 2+ distal pulses throughout
Neuro: alert, oriented, no focal motor/sensory deficits
Skin: warm, no rashes noted

ED Course:
As you ordered patient started on continuous neb, given IV methylpred, mag sulfate while IV, O2 via NRB started and placed on monitor.  Respiratory is en route with noninvasive ventilation and your tech is setting up intubation equipment and RSI medications in case necessary...

Labs are not yet back however you have access to the following EKG and CXR...

 

Despite continuous neb, iv corticosteroids and mg sulfate patient continues to have moderate respiratory distress...  repeat vitals are obtained:
T 99.5F      HR 130    BP  102/64    RR 44   SaO2 90% on NRB

• What is the diagnosis?  What treatment needs to be initiated for this?

General questions pertaining to asthma management in the ED...

•  What criteria can be used to determine suitability for admission to the hospital for patients with   asthma exacerbations?
• What criteria can be used to determine readiness for discharge from the ED or hospital?
  

   

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Diagnosis:  Tension Pneumothorax

Treatment: Needle decompression and chest tube placement

 What criteria can be used to determine suitability for admission to the hospital for patients with   asthma exacerbations?

After treatment in the emergency department for 1 to 3 hours, patients who have an incomplete or poor response, defined as an FEV₁ or PEF of less than 70% of the personal best or predicted value, should be evaluated for admission to the hospital. Patients who have an FEV₁ of less than 40%, continuing moderate-to-severe symptoms, drowsiness, confusion, or a partial pressure of arterial carbon dioxide of 42 mm Hg or greater should be admitted.

What criteria can be used to determine readiness for discharge from the ED or hospital?

According to the authors, patients may be discharged if the FEV₁ or PEF after treatment is 70% or more of the personal best or predicted value and the lung function and improvement of symptoms are sustained for at least 60 minutes. After discharge, patients should continue to use inhaled short-acting β₂-adrenergic agonists as needed and should be prescribed oral corticosteroids for 3 to 10 days.

Reference:

Lazarus, S. Emergency Treatment of Asthma. N Engl J Med 2010; 363:755-764

ACLS 2010 - Intro & Airway

Here's an introduction to ACLS 2010, an important skill you should pick up not only for your ER rotation, but for all your rotations! Let me know if you have any questions. I'll be putting up more vids as I make 'em.

Again, leave me feedback in the comments.

The first part of ACLS is A and B... yes, the order has changed to CAB for adults suffering from likely cardiac causes, but I'm old fashioned, so let's cover A & B first...

So let's talk about capnography and intubations, etc. The use of capnography is a big change in the new 2010 guidelines. Looks like we got some new equipment to buy.

Treatment of Status Epilepticus

Here's a quick video on the treatment of Status Epilepticus, one of the few neurologic emergencies we see in the Emergency Department. This is a method I'm experimenting with (you can see more videos at my EM Blog. Feel free to ask questions and comment on the format (I could use the feedback).

Introduction to EPIC 05 - Discharging Patients

And this last morsel is on how to discharge patients. One point I'd like to stress is to remember that this is information patients take home and likely the only thing they'll remember. What you tell them often gets quickly forgotten. So document your instructions clearly in a language they can understand.

Introduction to EPIC 04 - Admitting Patients

This video covers how to admit a patient to the floor. Remember these few points:

• You can't enter a diagnosis (and shouldn't - it messes things up later)
• Ask the attending with whom you're working to enter the Dx
• Tell the clerks the patient is "ready to move" or your patient will never get a bed

Introduction to EPIC 03 - Order Entry & Procedures

Here the inimitable Dr. Casey describes the process of placing orders, the use of order sets and the documentation of procedures using procedure templates. Enjoy. Maybe with a glass of Chardonnay.

Introduction to EPIC 02 - Documentation

Here's a very quick introduction to documentation.

Introduction to EPIC 01 - Main Tracking Board

Hello all,

This is the first of five very short videos introducing you to EPIC ASAP (the ER module of EPIC). Please feel free to watch as many times as you need to and ask any questions. Here are the delicious videos:

1. Main Tracking Board
2. Documenting
3. Order Entry & Procedures
4. Admitting Patients
5. Discharging Patients