Preparation_ Organisation Protocols

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					Preparation, Organisation

   Why POP stops you going pop

    Dr David Rimmer Oct 2010
Is your butt covered in an emergency?
Session Overview
 Communication
 Cardiac
 Shortness of breath
 Practice Session on mannequins
 Envenomation
 Trauma
 Stroke
 Initial IV therapy
 Fitting
 Info in from the patient to the team

 Info shared within the team

 Info out     from the team to QAS, ED
What is a team?
“A team is a group with a specific task or tasks, the accomplishment of which requires
   the interdependent and collaborative efforts of its members.” *

What is a system?
Systems provide clarity, predictability;
good systems also provide efficiency.
Furthermore, it is questionable as to whether
effective teamwork can be achieved without systems.
Why Teamwork?

       The involvement of practice staff in
     decisions regarding quality improvement
          and changes within the practice
     positively influenced work relationships
           and quality of care delivered
Key elements of an effective team

                       Clear goals

                       Division of labour



  The Previous Slide again
  (Translated for Doctors)
 Whatcha gunna do?
 Who’s gunna do It?
 What are the others gunna do?
 How do ya know who’s gunna do It?
 How do ya organise who’s gunna do It?
 How do you practice who’s gunna do It?
 Most of this lecture is about the gunna’s more than the Its
     Info in (AMPLE OLD CART)
 Allergies               •Onset
 Medications             •Location
 Past History            •Duration
 Last ate/ drank   •Characteristics
 Events            •Aggravating
                    •Treatment so far
Info within --- Sharing with NERDs
  Prior allocation of roles within the team

  Nurse - Equipment Setup Assist Observations Access
  Extra person - Scribe, Document, Relatives communication
  Receptionist - QAS Demographics Damage Control
  Doctors -Fluff and Panic while appearing in control
Consistent Approach
           •   Setting up Protocols
           •Using your medical software to set up
           shortcuts in progress notes
           • e.g “AMPLE OLD CART”

           •Template to ensure accurate information
           for the QAS and ED.
Info out ---
  What do the QAS /ED team need to know?
  The Heads Up call.
  Accurate demographics.
  AMPLE history
  Treatment so far including Obs. (weight essential for kids)
  Reliable patient past history summary.

  Why?? ED Triage categories

 Applying the POP principles?

 to Communication?
Cardiac - Preparation

Basic Life Support Charts
Adult Life Support Charts
Paediatric Life Support Charts
The Cafe Coronary ..... Foreign Body Airway obstruction
Cardiac - Organisation

Stay n Play
Scrape n Run

Time is muscle – reperfusion is what it is all about.

Environment – space, access and privacy
Cardiac -Protocols
1.  MONA –
 Cannulation
 12 lead ECG – Note any ST elevation or abnormal
  arrthymias and request IC paramedic.

 Applying the POP Principles?

 to Cardiac?
SOB – The big As
 Anaphylaxitive
 Acute Pulmonary Oedema
 Acidosis
 Asthma
 Anxiety
Guedels Airway
Nasopharyngeal Airway
Laryngeal Mask Airways
Mild to moderate allergic reaction

• Tingling of the mouth
• Hives, welts or body redness
• Swelling of the face, lips, eyes
• Vomiting, abdominal pain (why?)
Anaphylaxitive - Severe

 • Difficulty and/or noisy breathing
  • Swelling of the tongue
  • Swelling or tightness in the throat
  • Difficulty talking or hoarse voice
  • Wheeze or persistent cough
  • Loss of consciousness and/or collapse
  • Pale and floppy (young children)
             ADRENALINE 1: 1,000 (1ml)
             10kg weight for 0.1 ml adrenaline 1:1000
             Dilute 1ml in 10 for IV use (minijets)

             S/C, then NEBULISE IF NO IV
             ONLY Adrenaline is lifesaving in anaphylaxis!

             Adult – most people can guess weight to
             nearest 10 kg up to 100 kg. Can always
             give more, much harder to give less
             Child weight guessing??
Kids weight
 RCH Brisbane protocol.
 Infants <12 months = half of (age in months +9)
 Children 1-5            = twice (age in years +5)
 Children 5-14          = 4 x age in years.

 For adrenaline, the Kiss principle is
 ADRENALINE 1: 1,000 (1ml)
 Adult – 0.5ml (have 2 syringes drawn up, one for each 50 kg,
  whack in the first one and then think what their weight is.
 Child – 0.25ml (how old is a 25 kg child)
 Baby – 0.15ml (how old is a 15 kg child)
Other Preparation
 Antihistamine H1 AND H2
 IV Cannula (son of a gun)
 Fluids
 Call 000 and request an IC paramedic
Acute Pulmonary Oedema
 GTN Spray, then patch
 02
 Cannulation
 Posture – sitting upright
 Key factor is time to BiPAP
 Morphine is old hat?
•   Reassurance ++++++

•   02

•   Salbutamol, Adrenaline in more severe cases


•   Call 000

•   IV Cannula, are you gunna get one in?

•   IV Fluids

 Anxiety – is a positive diagnosis
 Hyperventilation produces alkalosis. Bodies are smart, if
  they are acidotic, they will compensate by hyperventilating.
 Causes of acidosis.
   Metabolic
   Respiratory
Metabolic acidosis
 Some causes of an elevated anion gap metabolic acidosis is
  represented by the mnemonic MUDPILES:
   Methanol
   Uremia
   Diabetic ketoacidosis
   Paraldehyde
   Iron, isoniazid (INH)
   Lactic acid
   Ethanol, ethylene glycol
   Salicylates
Matabolic acidosis
 A normal anion gap metabolic acidosis occurs when loss of
  bicarbonate from the GI tract or kidneys is excessive or when
  hydrogen ions cannot be secreted because of renal failure.
  The causes can be represented by the mnemonic
   Ureterostomy
   Small bowel fistula
   Extra chloride
   Diarrhoea
   Carbonic anhydrase inhibitors (eg, acetazolamide)
   Adrenal insufficiency
   Renal Tubular Aacidosis
   Pancreatic fistula
Respiratory acidosis
 Acute
 Caused by abrupt failure of ventilation.
 depression of the central respiratory center by cerebral
  disease or drugs
 inability to ventilate adequately due to neuromuscular disease
  (e.g., myasthenia gravis, amyotrophic lateral sclerosis,
  Guillain-Barré syndrome, muscular dystrophy)
 airway obstruction related to asthma or chronic obstructive
  pulmonary disease (COPD) exacerbation.
 Chronic. When oxygen is bad for you

 Applying the POP Principles?

 to SOB?
Spider bites
           •Pain Relief – Ice, Panadol ? Morphine
Big and Black
           Funnel Web spiders – PIT – Pressure Immobilization      Technique
Small and Red
           Red Back – Ice and Pain relief.
Necrotising arachnoiditis

Fish Envenomation
          Bullrout and Stone Fish
          Remove Barbs, hot water (20 minutes) , if necessary IV               analgesia

          Treat all seriously – PIT
          Treat symptomatically
          IV Cannula and fluids
Envenomation ctd
 Jelly Fish
         Box Jellyfish (Vinegar) – QAS 000
         Blue Bottles (no vinegar)
         Irakandji ??

 Pain Relief, remove Tentacles without discharging

 ABC always

 Applying the POP Principles?

 to Envenomation?
Trauma A B C
 Golden hour (golden how long??)
 Airway with C Spine protection
 Breathing
 Circulation.
 Disability.
Where do these fit into ABC

  Head Injury – Glasgow Scale / AVPU
      AVPU Alert Verbal Pain Unconscious
      GCS M6V5E4
  Spine immobilisation.
  Pain relief
   IV Cannula
  Leave splinting to QAS, can consider axial
  traction if limb threatening deformity
 Elements of the scale
 4 eye, 5 verbal and 6 motor responses. The three
  values separately as well as their sum are
  considered. The lowest possible GCS (the sum) is 3
  (deep coma or death), while the highest is 15 (fully
  awake person).
 Individual elements as well as the sum of the score
  are important. Hence, the score is expressed in the
  form "GCS 9 = E2 V4 M3 at 07:35".
 Communication involves expectations!

 Applying the POP Principles?

 to Trauma?
But the collar is a pain!! OOOPS
 What is FAST?
    FAST requires an assessment of three specific symptoms of
   Facial weakness - can the person smile? Has their mouth or
    eye drooped?
   Arm weakness - can the person raise both arms?
   Speech problems - can the person speak clearly and
    understand what you say?
   Time to call 000
Case 1
 A.D.
 42 YR MALE

 Came in from gardening

 Blurred vision, falling to right with walking,
 Wife noticed slurred speech right facial droop

 GP called, call put straight through to you
What do you advise her to do?

(1) Tell her to bring him to the surgery for full history and
    examination for a detailed neurological examination?

(2) Tell her to drive him to hospital

(3) Call Q.A.S.& arrange transport to nearest ED

(4) Wait and see if there is any recovery in short term
        WEC Results 2007-2010
      25,000 patients per year, everything in place

       13 patients treated with thrombolysis
            (3% of stroke presentations)
 1 SICH
 1 Death
 1 dramatic response
 2 possible improvements
 The rest unchanged

 r-Tissue Plasminogen Activator

 0.9mg /kg 10% bolus remainder over 1 hour

 Admitted to ICU
WEC Thrombolysis Protocol

 Exclusions.

Time of onset of stroke
 Greater than 3 hours to treatment
 Uncertain
 During sleep and period of sleep to treatment greater than 3

 Stroke or head injury in previous 3 months
 Major trauma in 30 days
 Myocardial infarction in 3 months
 Arterial puncture at non compressible site in 7 days
 Major surgery 14 days
 Visceral bleeding 21 days
 Previous ICH
 Age <18 or>80
Examination Contraindications.
 Systolic BP>185 or <100
 Diastolic BP >110
 Overt bleeding

Neurological Contraindications.
 Signs rapidly improving
 Sign very localized or NIHSS<4
 Signs represent major ischemic stroke NIHSS>20
 CT Contraindications.
 Mass effect
 Early signs of large stroke

 Coagulation profile contraindications.
 Anticoagulants other than aspirin
 INR.1.5 OR increased APTT
 Thrombocytopenia <100
WEC Exclusion Reasons

 Applying the POP Principles?

 to Stroke?
Initial IV Therapy
 Choice 1    Normal Saline
 Choice 2    Normal Saline
 Choice 3    When is it not Normal Saline???
  When it is normal saline. Why?
 The Hartmann’s controversy
 The crystalloid vs colloid issues

The Gun (s)
Simple IV, how long do you play
Central lines in an emergency.
 Femoral NAV
Interosseous infusion
The numbers
Crook      10 mls per kilo
Bluddy crook 20 mls per kilo.
Fluid challenge concept.
Importance of observations and

 Applying the POP Principles?

 to IV therapy?
 Get the basics right

 Febrile Convulsions will self terminate while you are moving
  along your protocol pathway.
 Changes in the management of status epilepticus.

 Let’s watch Dr Le Cong’s Powerpoint and then POP that.
Current concepts in status
      By Dr Minh Le Cong
         RFDS Cairns
         October 2010
 “Emergency treatment of status epilepticus : current
  thinking”,Dan Millikan,MD,Brian Rice,MD,Robert
 Emerg Med Clin N Am 27 (2009) 101–113

 “Treatment strategies for status epilepticus” Timothy Begany
, June 2000
What is the definition of status
A. Seizure of any duration
B. Seizure >30min
C. Seizure >10min
D. Two seizures without any
 recovery in alertness in between
E. Seizure >5 min
New definition
 Generalized convulsive status epilepticus in adults and
   older children (greater than 5 years old) refers to:

 > 5 minutes of a continuous seizure, or two or more
  discrete seizures between which there is incomplete
                recovery of consciousness.
Why new definition?
> 5min unlikely to respond to usual
Neuronal injury occurs under 30
30 min is a long time to watch
 someone fitting away….
Status Epilepticus?

  What is your practice’s approach to
        someone who is fitting?
Updates in approach to SE
 Faster and more aggressive
 Terminate fit as early as possible using
  whatever means
 First line benzodiazepines and/or
 Second line general anaesthesia
What’s that you say?
 If fits recur after benzodiazepine
 Give phenytoin along with general anaesthetic

 Choice of anaesthetic
   Midazolam ( first line for kids)
   Propofol (first line for adults)
   Ketamine ( first line for everybody)
Prehospital SE care
IMI midazolam
IN midazolam
Rectal midazolam/diazepam
Ketamine ( IMI or IN)
Airway management ( ETI vs LMA)
Intranasal drug delivery using MAD
 Status epilepticus = greater than 5 min
  or 2 discrete seizures with no inter-ictal
 Benzos first line
 General anaesthesia second line +/-
 Stop fitting ASAP

 Applying the POP Principles?

 to Fitting?

 Comments and Thanks