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Procedures, Skills & Administration
Model of the Clinical Practice of Emergency Medicine 2009
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- Appendix 1
- Procedures and skills integral to the practice of EM
- Appendix 2
- Other components and core competencies of the practice of EM
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Procedures
Airway (1)
Cricothyroidotomy
- Absolute contraindications?
- Relative contraindications
- Age < 10 (leads to subglottic stenosis)
- Bleeding diathesis
- Poor landmarks
- Complications
- Hemorrhage, aspiration, misplaced tube, hypoxemia, neurovascular injury, mediastinal emphysema
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Needle cricothyroidotomy is the emergency surgical airway of choice for age < 10
Airway (2)
- Transtracheal jet ventilation (PTJV)
- Temporizing device
- Provides temporary oxygenation/ventilation
- Limitation: Hypercapnea
- 4:1 expiratory/inspiratory ratio
- 2.8-3.0 mm I.D./ 6 F kink resistant catheter
- 50 psi
- Max: 30 minutes
- Facilitates ETT placement due to glottic opening
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Airway (3)
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Airway (3)
Confirmation of endotracheal intubation
- Visualization
- Auscultation
- Capnometry
- Reliable if pulse is present
- False negative in cardiac arrest
- Esophageal detector devices
- Bulb does not re-expand in esophageal intubation
- False negatives: pregnancy, obesity, COPD
- False positives: uncommon
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- Chest x-ray: used to rule out right main stem intubation
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Airway(4)
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- CAPNOGRAPHY: A VALUABLE TOOL FOR AIRWAY MANAGEMENT, Nagler, J., et al, Emerg Med Clin North Am, 26(4): 881, November 2008.
Indications
Procedural sedation
BIPAP
DKA
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Mech Ventilated Pts
Regional Nerve Blocks
Radial Nerve Block
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- Supination
- 3-5 cm proximal to the joint
- 10cc lidocaine or bupivicaine
Ulnar Nerve Block
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- Supination
- 3 finger widths from distal crease
- Inject between the flexor carpi ulnaris and the ulnar artery. Paresthesias, withdraw slightly and inject
- 3-5 cc lidocaine or bupivicaine
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Median Nerve Block
- Inject between the flexor carpi radialis and the palmaris longus
- 3-5cc lidocaine or bupivicaine
Ankle Blocks (1)
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- Superficial peroneal nerve
- Inject SQ between the lateral maleolus and the anterior border of the tibia
- Posterior tibial nerve
- Medial aspect of the calcaneal tendon anterior toward the posterior tibia. The nerve is just posterior to the tibial artery.
- If paresthesias, inject 3-5 cc
- If not, contact the tibia and inject 5-7 cc
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Ankle Blocks (2)
Paracentesis
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- Contraindications
Thomsen TW, Shaffer RW, et al. Paracentesis. N Engl J Med. Nov 2006;355(19):e21.
- Acute abdomen (absolute)
- Platelet less than 20K
- INR greater than 2.0
- Pregnancy
- Distended bladder
- Distended bowel
- Cellulitis
- Adhesions
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Excision of Thrombosed Hemorrhoids
- 48-72 hours within onset of symptoms
- Local infiltration of lidocaine
- Elliptical incision/ excision of clot and overlying skin
- > 72 hours, conservative medical therapy
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Nail Trephination
- Trephination as good as nail bed exploration
- Needle or cautery
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Wound Care
Karounis et al. COSMETIC OUTCOMES WITH ABSORBABLE VS. NONABSORBABLE SUTURES ACAD EMERG MED. July 2004, Vol. 11, No. 7
- Absorbable plain gut suture
- No need for suture removal
- No difference in cosmetic result
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New AHA Guidelines
- BLS
- ACLS
- PALS
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BLS
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Summary
- The simplified universal adult BLS algorithm has been created (Figure 2).
- Refinements have been made to recommendations for immediate recognition and activation of the emergency response system based on signs of unresponsiveness, as well as initiation of CPR if the victim is unresponsive with no breathing or no normal breathing (ie, victim is only gasping).
- "Look, listen, and feel for breathing" has been removed from the algorithm.
- Continued emphasis has been placed on high-quality CPR (with chest compressions of adequate rate and depth, allowing complete chest recoil after each compression, minimizing interruptions in compressions, and avoiding excessive ventilation).
- There has been a change in the recommended sequence for the lone rescuer to initiate chest compressions before giving rescue breaths (C-A-B rather than A-B-C). The lone rescuer should begin CPR with 30 compressions rather than 2 ventilations to reduce delay to first compression.
- Compression rate should be at least 100/min (rather than "approximately" 100/min).
- Compression depth for adults has been changed from the range of 1½ to 2 inches to at least 2 inches (5 cm).
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This download link is referred from the post: MBBS 2025 Lecture Notes for all subjects