tag:blogger.com,1999:blog-42819449814243265872024-02-07T13:25:44.834+10:00IVLineAaron Sparshotthttp://www.blogger.com/profile/16868086818074290497noreply@blogger.comBlogger194112tag:blogger.com,1999:blog-4281944981424326587.post-62644862757146594692018-11-09T12:45:00.002+10:002018-11-09T12:48:33.634+10:00REM: Acute Agitation / Behavioural Disturbance<div dir="ltr" style="text-align: left;" trbidi="on">
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Acutely agitated patients are uniquely challenging for Rural Hospitals who are often limited by the Health and Support Staff available. These patients can be at high risk of harm to themselves and others, if not managed carefully as several Coroner's cases in Australia have highlighted.<br />
<br />
The major issues in assessment of the acutely agitated patient as outlined by the Consensus Statement on The Acutely Agitated Patient in a Remote Location are:<br />
<ol style="text-align: left;">
<li>Safety</li>
<li>Medico-legal</li>
<li>Medical assessment</li>
<li>Mental health assessment</li>
<li>Follow-up/Disposition</li>
</ol>
<br />
The objective of the initial evaluation is not a definitive diagnosis, but a differential diagnosis that informs immediate management of acutely agitate patient, so that more detailed evaluation, management and disposition are possible.<br />
<br />
This is part of the <a href="http://www.ivline.org/2018/06/acrrm-emergency-medicine-study-guide.html">Rural Emergency Module</a> series (designed in particular for ACRRM Trainees).<br />
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<b style="mso-bidi-font-weight: normal;"><span style="color: #ffc000; mso-themecolor: accent4;">Initial Assessment
and Management<o:p></o:p></span></b></h2>
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<br />
<b><span style="color: orange;">Recognition</span></b><br />
<ul style="text-align: left;">
<li><span style="color: orange;">Recognise, check for Danger and perform a Risk Assessment</span></li>
<li><span style="color: orange;">Send for help, gather resources and appropriate equipment.</span></li>
<li><span style="color: orange;">Move to appropriate area (e.g. quiet room, visible area, rooms with multiple exits, etc).</span></li>
<li><span style="color: orange;">Monitoring if chemical sedation utilised prehospital: SpO2, HR, BP, Cardiac Monitoring, EtCO2</span></li>
<li><span style="color: orange;">Consider whether this patient is voluntary vs involuntary.</span></li>
<li><span style="color: orange;">Consider Telephysciatry Support and/or advice from Emergency/Anaesthetic Specialists</span></li>
</ul>
<span style="color: #e69138;"><b>Provide Low Stimulus and a Calm Environment</b></span><br />
<div>
<span style="color: #e69138;"><b><br /></b></span></div>
<span style="color: #e69138;"><b>Rapid ABCDE Assessment</b></span><br />
<div style="text-align: left;">
<span style="color: #e69138;">Perform a Rapid ACBCE assessment in attempt to identify and manage easily reversible causes;</span></div>
<ul>
<li><span style="color: #e69138;">Assess for Hypoxia</span></li>
<li><span style="color: #e69138;">Check for Hypoglycaemia</span></li>
<li><span style="color: #e69138;">Provide analgesia for pain</span></li>
<li><span style="color: #e69138;">Hunger/thirst (but keep in mind scenarios where fasting may be appropriate)</span></li>
<li><span style="color: #e69138;">Empty bladder/bowels with adequate toileting</span></li>
<li><span style="color: #e69138;">Nicotine addiction (offer nicotine replacement early)</span></li>
<li><span style="color: #e69138;">Drug withdrawal </span></li>
</ul>
<span style="color: #e69138;"><b>Risk Assessment</b></span><br />
<ul style="text-align: left;">
<li><span style="color: #e69138;">Evaluate Safety for both the patient, clinician and others</span></li>
<li><span style="color: #e69138;">Patient has weapons.</span></li>
<li><span style="color: #e69138;">Previous History of Violence and/or Aggression</span></li>
<li><span style="color: #e69138;">Intoxication / Drug Ingestion (e.g. Alcohol / Methamphetamine)</span></li>
<li><span style="color: #e69138;">Known environmental stressors in last 7 days (personal loss, relationship crisis, financial crisis etc but excluding hospital admission.)</span></li>
<li><span style="color: #e69138;">Previous sedative medication use</span></li>
<li><span style="color: #e69138;">Past Medical History (see below)</span></li>
</ul>
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<span style="color: #e69138;"><br /></span></div>
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<span style="color: #e69138;"><b>Primary Assessment</b></span><br />
<span style="color: #e69138;">When it is safe to do so (for both you and the patient) conduct a Primary Medical Assessment to ensure there are no other organic or immediately reversible causes for the patient's agitation.</span><br />
<span style="color: #e69138;"><br /></span>
<span style="color: #e69138;">Again the patient may require chemical sedation before an initial assessment can be conducted.</span><br />
<span style="color: #e69138;"><br /></span>
<span style="color: #e69138;"><b>Airway</b>:</span><br />
<ul style="text-align: left;">
<li><span style="color: #e69138;">Assess for airway patency (i.e. <i>obstruction</i>) and protection (<i>decreased GCS</i>)</span></li>
</ul>
<span style="color: #e69138;"><b>Breathing</b>:</span><br />
<ul style="text-align: left;">
<li><span style="color: #e69138;">Assess effort and efficacy of breathing, respiratory rate</span></li>
<li><span style="color: #e69138;">Avoid hypoxia / hypercarbia which can predispose the patient towards agitation</span></li>
<li><span style="color: #e69138;">Provide supplemental high flow oxygen as indicated, aim SpO2 >90%</span></li>
</ul>
<span style="color: #e69138;"><b>Circulation</b>:</span><br />
<ul>
<li><span style="color: #e69138;">Assess heart rate, blood pressure and capillary refill</span></li>
<li><span style="color: #e69138;">ECG when safe to do so.</span></li>
<li><span style="color: #e69138;">Gain IV Access when safe to do so</span></li>
</ul>
<span style="color: #e69138;"><b>Disability</b>:</span><br />
<ul style="text-align: left;">
<li><span style="color: #e69138;">Monitor patients level of consciousness and agitation (use of the <a href="https://www.mdcalc.com/richmond-agitation-sedation-scale-rass">Richmond Agitation-Sedation Score</a> may be useful and allow for titration of medications). </span></li>
<li><span style="color: #e69138;">Check BSL + ketones</span></li>
</ul>
<span style="color: #e69138;"><b>Exposure</b>:</span><br />
<ul style="text-align: left;">
<li><span style="color: #e69138;">Check temperature</span></li>
<li><span style="color: #e69138;">Check for signs of injury and/or infection</span></li>
</ul>
<div>
<span style="color: #e69138;"><br /></span></div>
<span style="color: #e69138;"><b>Mental Health Assessment</b></span><br />
<ul style="text-align: left;">
<li><span style="color: #e69138;">General appearance</span></li>
<li><span style="color: #e69138;">Behaviour</span></li>
<li><span style="color: #e69138;">Speech</span></li>
<li><span style="color: #e69138;">Cooperativeness/level of insight</span></li>
<li><span style="color: #e69138;">Specific thoughts of self harm or violence</span></li>
<li><span style="color: #e69138;">Delusional ideation, hallucinations</span></li>
</ul>
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<b style="mso-bidi-font-weight: normal;"><span style="color: #222a35; mso-themecolor: text2; mso-themeshade: 128;">History</span><o:p></o:p></b></h2>
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<span style="color: #0b5394;"><b>Signs/symptoms</b></span><br />
<ul style="text-align: left;">
<li><span style="color: #0b5394;">Seizure activity</span></li>
<li><span style="color: #0b5394;">Airway obstruction / compromise</span></li>
<li><span style="color: #0b5394;">Respiratory distress / hypoxia</span></li>
<li><span style="color: #0b5394;">Fevers</span></li>
<li><span style="color: #0b5394;">Features of Toxidromes</span></li>
</ul>
<b style="color: #0b5394;">Allergies</b><br />
<span style="color: #0b5394;"><b>Meds</b> </span><br />
<ul style="text-align: left;">
<li><span style="color: #0b5394;">Antiepileptics</span></li>
<li><span style="color: #0b5394;">Antipsychotics, antidepressants,</span></li>
<li><span style="color: #0b5394;">Recreational drugs, drug withdrawal</span></li>
</ul>
<b style="color: #0b5394;">PMHx</b><span style="color: #0b5394;">:</span><br />
<ul style="text-align: left;">
<li><span style="color: #0b5394;">Dementia</span></li>
<li><span style="color: #0b5394;">Acquired Brain Injury</span></li>
<li><span style="color: #0b5394;">Alcohol +/- drug abuse</span></li>
<li><span style="color: #0b5394;">Epilepsy</span></li>
<li><span style="color: #0b5394;">Mental Health</span></li>
<ul>
<li><span style="color: #0b5394;">Schizophrenia</span></li>
<li><span style="color: #0b5394;">Bipolar Affective Disorder</span></li>
</ul>
<li><span style="color: #0b5394;">Development Disorders: Intellectual Disability, Autism Spectrum Disorder</span></li>
</ul>
<b style="color: #0b5394;">Last oral intake</b><br />
<ul style="text-align: left;">
<li><span style="color: #0b5394;">Poison ingestion</span></li>
</ul>
<span style="color: #0b5394;"><b>Events</b></span><br />
<ul style="text-align: left;">
<li><span style="color: #073763;">Events leading up to hospital presentation (e.g. Brought in by Police)</span></li>
</ul>
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<b style="mso-bidi-font-weight: normal;"><span style="color: #ff33ff;">Investigations</span></b><b style="mso-bidi-font-weight: normal;"><span style="color: #5f0272;"><o:p></o:p></span></b></h2>
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<b><span style="color: purple;">Point of care</span></b><br />
<ul style="text-align: left;">
<li><span style="color: purple;">Blood Sugar Levels + Ketones</span></li>
<li><span style="color: purple;">Arterial/Venous Blood Gas</span></li>
<li><span style="color: purple;">Urine analysis and drug screen</span></li>
<li><span style="color: purple;">ECG</span></li>
</ul>
<b><span style="color: purple;">Laboratory</span></b><br />
<ul style="text-align: left;">
<li><span style="color: purple;">FBC, Urea and Electrolytes</span></li>
<li><span style="color: purple;">Drug Levels</span></li>
<li><span style="color: purple;">As available and indicated; B12/Folate, TFTs, ESR, CRP</span></li>
</ul>
<span style="color: purple;"><b>Imaging (</b>a</span><span style="color: purple;">s indicated/available)</span><br />
<ul style="text-align: left;">
<li><span style="color: purple;">Bladder scan / Ultrasound</span></li>
<li><span style="color: purple;">CXR</span></li>
<li><span style="color: purple;">CT Head</span></li>
</ul>
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<b style="mso-bidi-font-weight: normal;"><span style="color: #009242;">Management<o:p></o:p></span></b></h2>
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<h4 style="text-align: left;">
<span style="color: #38761d;">
Verbal De-escalation</span></h4>
<ul style="text-align: left;">
<li><span style="color: #6aa84f;">Find a calm and clear environment</span></li>
<li><span style="color: #6aa84f;">Introduce self, explain your role.</span></li>
<li><span style="color: #6aa84f;">Be emphatic, but direct in your language</span></li>
<li><span style="color: #6aa84f;">Offer support; food, water, phone call</span></li>
<li><span style="color: #6aa84f;">Utilise family, friends or social supports from the community</span></li>
<li><span style="color: #6aa84f;">Assess responsiveness to verbal de-escalation</span></li>
</ul>
<div>
<span style="color: #6aa84f;"><br /></span></div>
<h4 style="text-align: left;">
<span style="color: #38761d;">
Physical Restraint</span></h4>
<div>
<ul style="text-align: left;">
<li><span style="color: #6aa84f;">Call Security / Police / Support Staff - consider a show of force first</span></li>
<li><span style="color: #6aa84f;">Use typically as an adjunct to Chemical Sedation.</span></li>
<li><span style="color: #6aa84f;">Will normally require at least 5 people to hold down an individual safely. However in Rural settings may have insufficient staff to achieve this.</span></li>
<li><span style="color: #6aa84f;">Formal restraints may required before, during and after chemical sedation to limit further harm to the patient and others.</span></li>
</ul>
<div>
<span style="color: #6aa84f;"><br /></span></div>
</div>
<h4 style="text-align: left;">
<span style="color: #38761d;">
Chemical Sedation</span></h4>
<span style="color: #6aa84f;">Queensland Health provide one of many algorithmic approaches to the acutely agitated patient which can be reviewed here -> <a href="https://www.health.qld.gov.au/__data/assets/pdf_file/0031/629491/qh-gdl-438.pdf">QH-ASBD Algorithm</a>. </span><br />
<span style="color: #6aa84f;"><br /></span>
<br />
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<span style="color: #6aa84f;"><br /></span>
<span style="color: #6aa84f;"><b>Monitoring</b></span><br />
<span style="color: #6aa84f;">Use standard procedural sedation monitoring;</span><br />
<ul style="text-align: left;">
<li><span style="color: #6aa84f;">BP</span></li>
<li><span style="color: #6aa84f;">ECG or Cardiac Monitoring</span></li>
<li><span style="color: #6aa84f;">Pulse oximetry wiht SpO2 + HR</span></li>
<li><span style="color: #6aa84f;">RR</span></li>
<li><span style="color: #6aa84f;">EtCO2</span></li>
<li><span style="color: #6aa84f;">Regular assessment of conciousness or RASS</span></li>
</ul>
<br />
<span style="color: #6aa84f;"><b>Approach</b></span><br />
<span style="color: #6aa84f;">Below are some suggested dosing regimes however check your local health-service's guidelines. </span><br />
<span style="color: #6aa84f;">Generally most clinicians will select one sedative agent (e.g. benzodiazepine) and one anti-psychotic (e.g. olanzapine) agent, and avoid mixing multiple agents.</span><br />
<span style="color: #6aa84f;">Please also take the time to read up on the indications, contra-indications and side-effect profiles of each of the drugs.</span><br />
<span style="color: #6aa84f;"><br /></span>
<b><span style="color: #6aa84f;">Oral Sedation</span></b><br />
<ul style="text-align: left;">
<li><span style="color: #6aa84f;">Olanzapine: 10mg wafer PO Stat (up to a maximum of 30mg/24hrs.)</span></li>
<li><span style="color: #6aa84f;">Diazepam: 10-20mg PO Stat (up to a maximum of 60mg/24hrs.)</span></li>
</ul>
<b><span style="color: #6aa84f;">IM Sedation</span></b><br />
<ul style="text-align: left;">
<li><span style="color: #6aa84f;">Droperidol: 10mg IM, dose may be repeated after 15 mins (up to a maximum of 30mg/24hrs.)</span></li>
<li><span style="color: #6aa84f;">Haloperidol: 10mg IM, an alternative to Droperidol. More side effects.</span></li>
<li><span style="color: #6aa84f;">Ketamine: Failed sedation with above agents, consider 4-5mg/kg IM.</span></li>
<li><span style="color: #6aa84f;">Midazolam: 2.5 (elderly, frial) to 10mg (young, large). IM effect in 3 minutes.</span></li>
</ul>
<b><span style="color: #6aa84f;">IV Sedation</span></b><br />
<ul>
<li><span style="color: #6aa84f;">Droperidol: 5-10mg IV, (up to a maximum of 20mg/24hrs.)</span></li>
<li><span style="color: #6aa84f;">Haloperidol: 5-10mg IV, (up to a maximum of 20mg/24hrs.)</span></li>
<li><span style="color: #6aa84f;">Ketamine: 1-1.5mg/kg, titrate to RASS or Sedation Score.</span></li>
</ul>
<span style="color: #6aa84f;"><br /></span>
<b><span style="color: #6aa84f;">General Anaesthesia and Intubation</span></b><br />
<span style="color: #6aa84f;">Consider RSI only as last resort, bearing in mind the mental health risk vs the anaesthetic risk, and logistical factors.</span><br />
<br />
<h4 style="text-align: left;">
References</h4>
<b><span style="color: #444444;">Royal Flying Doctors Service The Acute Agitated Patient in a Remote Location</span></b><br />
<ul style="text-align: left;">
<li><span style="color: #444444; font-size: x-small;"><a href="https://www.flyingdoctor.org.au/assets/files/Consensus_Statement_-_The_Acutely_Agitated_Patient_in_a_remote_location.pdf">https://www.flyingdoctor.org.au/assets/files/Consensus_Statement_-_The_Acutely_Agitated_Patient_in_a_remote_location.pdf</a></span></li>
</ul>
<b><span style="color: #444444;">NSW Health: Management of Patients with Acute Severe Behavioural Disturbance in Emergency Departments</span></b><br />
<ul style="text-align: left;">
<li><a href="https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2015_007.pdf"><span style="color: #444444; font-size: x-small;">https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2015_007.pdf</span></a></li>
</ul>
<b><span style="color: #444444;">QLD Health: Management of Patients with Acute Severe Behavioural Disturbance in Emergency Departments</span></b><br />
<ul style="text-align: left;">
<li><a href="https://www.health.qld.gov.au/__data/assets/pdf_file/0031/629491/qh-gdl-438.pdf"><span style="color: #444444; font-size: x-small;">https://www.health.qld.gov.au/__data/assets/pdf_file/0031/629491/qh-gdl-438.pdf</span></a></li>
</ul>
<b><span style="color: #444444;">The Diagnostic Performance of the Richmond Agitation Sedation Scale for Detecting Delirium in Older Emergency Department Patients</span></b><br />
<ul style="text-align: left;">
<li><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4516221/"><span style="color: #444444; font-size: x-small;">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4516221/</span></a></li>
</ul>
<b><span style="color: #444444;">PHARM: Surviving Sedation Guidelines 2015</span></b><br />
<ul style="text-align: left;">
<li><a href="https://prehospitalmed.com/surviving-sedation-guidelines-2015/"><span style="color: #444444; font-size: x-small;">https://prehospitalmed.com/surviving-sedation-guidelines-2015/</span></a></li>
</ul>
<b><span style="color: #444444;">KI Docs: Lessons for management of acute agitation in Rural EDs</span></b><br />
<ul style="text-align: left;">
<li><a href="https://kidocs.org/2015/03/lessons-for-management-of-acute-agitation-in-rural-eds"><span style="color: #444444; font-size: x-small;">https://kidocs.org/2015/03/lessons-for-management-of-acute-agitation-in-rural-eds</span></a></li>
</ul>
</div>
Aaron Sparshotthttp://www.blogger.com/profile/16868086818074290497noreply@blogger.com0tag:blogger.com,1999:blog-4281944981424326587.post-55609104858583269762018-08-06T19:30:00.003+10:002022-01-28T17:08:42.709+10:00REM: Approach to the Seriously Ill Child<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="separator" style="clear: both; text-align: center;">
<a href="https://3.bp.blogspot.com/-oMPNyTpYDi4/W2WMPXBX1sI/AAAAAAAADTg/MsLkI9Tb_Ts80rzp6ss6YOOys8-kHETKgCLcBGAs/s1600/alleviate-children-fears-of-doctors.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="607" data-original-width="959" height="1" src="https://3.bp.blogspot.com/-oMPNyTpYDi4/W2WMPXBX1sI/AAAAAAAADTg/MsLkI9Tb_Ts80rzp6ss6YOOys8-kHETKgCLcBGAs/s640/alleviate-children-fears-of-doctors.jpg" width="1" /></a></div>
A seriously ill child that requires critical interventions is fortunately enough a rare event (even in urban settings). Children unlike adults however can typically not compensate for as long and require active management (that feeling of going fine than falling off a cliff) which can be particularly challenging in a rural setting. Secondly, there are the issues involving; anatomical & physiological differences in children, weight-based fluid and medication requirements, different equipment and potentially increased difficulty in performing procedures. All of this can up our fear levels and add to potentially ineffective management when it is required.<br />
<br />
Below is an simplistic approach to the seriously ill child. It is very general, but designed to give you a fall back point when it gets stressful. For disease/illness specific approaches take at look at the <a href="https://www.rch.org.au/clinicalguide/guideline_index/">Royal Children's Hospital Clinical Guidelines</a> or consider doing an Advanced Paediatric Life Support course.<br />
<br />
Neonatal resuscitation is a separate entity and will be covered at a later time.<br />
<br />
This is part of the <a href="http://www.ivline.org/2018/06/acrrm-emergency-medicine-study-guide.html">Rural Emergency Module</a> series (designed in particular for ACRRM Trainees).<br />
<div>
<br /></div>
<h3 style="text-align: left;">
Approach</h3>
<div>
<ol style="text-align: left;">
<li>Preparation</li>
<li>Recognition and First Snapshot</li>
<li>Primary Assessment & concurrent Resuscitative Management</li>
<li>Secondary Assessment & ongoing Emergency Treatment</li>
<li>Stabilisation and transfer to definitive care</li>
</ol>
<div>
<br /></div>
</div>
<h3 style="text-align: left;">
Preparation</h3>
Given the relative rarity and the angst around treating an unwell child in Rural Environments, preparation is key in trying to achieve the best outcomes. Rural sites can prepare by ensuring processes and checklists are in place, appropriate paediatric equipment (e.g. Non-invasive high-flow oxygen), streamlined referral and telehealth options, education and regularly conducting in-house simulations.<br />
<br />
The remainder of section will focus on how to prepare when you know a sick child is coming to your emergency department. For resuscitation preparation think <b>P A E D S</b>.<br />
<br />
<b>P eople</b><br />
<ul style="text-align: left;">
<li>Allocate roles (medical and nursing), team briefing, laboratory scientists, radiographer, social worker (for parents)</li>
<li>Crisis Resource Management Skills<br /><a href="https://emergencypedia.com/crisis-resource-management-skills/">https://emergencypedia.com/crisis-resource-management-skills/</a></li>
<li>Towards a Calmer Resus:<br /><a href="https://dontforgetthebubbles.com/tim-h/">https://dontforgetthebubbles.com/tim-h/</a></li>
</ul>
<b>A rea</b><br />
<ul style="text-align: left;">
<li>This is typically your resuscitation area in rural facilities, preferably one that has tele-health capacities.</li>
</ul>
<b>E quipment</b><br />
<ul style="text-align: left;">
<li>Rural and Remote Emergency Resus Trolley<br /><a href="https://www.health.qld.gov.au/__data/assets/pdf_file/0034/678625/rress-resus-trolley-v2.0.pdf">https://www.health.qld.gov.au/__data/assets/pdf_file/0034/678625/rress-resus-trolley-v2.0.pdf</a></li>
<li>Intra-oesssous kit</li>
</ul>
<b>D rugs</b><br />
<ul style="text-align: left;">
<li>Children's Health Queensland<br /><a href="https://www.childrens.health.qld.gov.au/qpec-paediatric-resuscitation-tools/#tab-6ff1bb73468033104a2">https://www.childrens.health.qld.gov.au/qpec-paediatric-resuscitation-tools</a></li><li>Monash Paediatric Emergency Drug Book<br /><a href="https://monashchildrenshospital.org/for-health-professionals/resources/resuscitation/">https://monashchildrenshospital.org/for-health-professionals/resources/resuscitation/</a></li>
<li>RCH: Emergency Drug Doses<br /><a href="https://www.rch.org.au/clinicalguide/guideline_index/Emergency_Drug_Doses/">https://www.rch.org.au/clinicalguide/guideline_index/Emergency_Drug_Doses/</a></li>
<li>CrashCall:<br /><a href="http://www.nwts.nhs.uk/documentation/crashcall">http://www.nwts.nhs.uk/documentation/crashcall</a></li>
<li>Starship Child Health:<br /><a href="http://www.paediatricdrugs.net/EnterPtData.aspx">http://www.paediatricdrugs.net/EnterPtData.aspx</a></li>
</ul>
<div style="text-align: left;">
<b>S end for Help</b></div>
<ul style="text-align: left;">
<li>External help (Paediatricians, Intensivists), Retrieval Services</li>
</ul>
<br />
<h3 style="text-align: left;">
Recognition & First Snapshot</h3>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://2.bp.blogspot.com/-RoaFtxqXlmI/W2fBYy-YgJI/AAAAAAAADT0/RSBo3p1ykX8outZv9iAkRBjmiB5QZzFOQCLcBGAs/s1600/PAT%2Bassessment.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="300" data-original-width="600" src="https://2.bp.blogspot.com/-RoaFtxqXlmI/W2fBYy-YgJI/AAAAAAAADT0/RSBo3p1ykX8outZv9iAkRBjmiB5QZzFOQCLcBGAs/s1600/PAT%2Bassessment.png" /></a></div>
<br />
<br />
<h3 style="text-align: left;">
Primary Assessment</h3>
<div>
The aim of the primary assessment in seriously ill children and infants is to identify the physiological abnormalities, and initiate the most appropriate management strategy to correct these abnormalities.</div>
<h4 style="text-align: left;">
<table border="1" cellpadding="0" cellspacing="0" class="MsoTable15Grid4Accent1" style="border-collapse: collapse; border: none; mso-border-alt: solid #8EAADB .5pt; mso-border-themecolor: accent1; mso-border-themetint: 153; mso-padding-alt: 0cm 5.4pt 0cm 5.4pt; mso-yfti-tbllook: 1184; width: 548px;">
<tbody>
<tr style="height: 27.9pt; mso-yfti-firstrow: yes; mso-yfti-irow: -1; mso-yfti-lastfirstrow: yes;">
<td style="background: rgb(68, 114, 196); border-right: none; border: 1pt solid rgb(68, 114, 196); height: 27.9pt; mso-background-themecolor: accent1; mso-border-bottom-alt: solid #4472C4 .5pt; mso-border-bottom-themecolor: accent1; mso-border-left-alt: solid #4472C4 .5pt; mso-border-left-themecolor: accent1; mso-border-themecolor: accent1; mso-border-top-alt: solid #4472C4 .5pt; mso-border-top-themecolor: accent1; padding: 0cm 5.4pt; width: 91.9pt;" width="123"><div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 0cm; mso-yfti-cnfc: 5; text-align: center;">
<b><span face=""arial" , sans-serif" style="color: white; font-size: 10pt;">Airway and Breathing<o:p></o:p></span></b></div>
</td>
<td style="background: rgb(68, 114, 196); border-bottom: 1pt solid rgb(68, 114, 196); border-left: none; border-right: none; border-top: 1pt solid rgb(68, 114, 196); height: 27.9pt; mso-background-themecolor: accent1; mso-border-bottom-alt: solid #4472C4 .5pt; mso-border-bottom-themecolor: accent1; mso-border-top-alt: solid #4472C4 .5pt; mso-border-top-themecolor: accent1; padding: 0cm 5.4pt; width: 120.5pt;" width="161"><div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 0cm; mso-yfti-cnfc: 1; text-align: center;">
<b><span face=""arial" , sans-serif" style="color: white; font-size: 10pt;">Circulation<o:p></o:p></span></b></div>
</td>
<td style="background: rgb(68, 114, 196); border-bottom: 1pt solid rgb(68, 114, 196); border-left: none; border-right: none; border-top: 1pt solid rgb(68, 114, 196); height: 27.9pt; mso-background-themecolor: accent1; mso-border-bottom-alt: solid #4472C4 .5pt; mso-border-bottom-themecolor: accent1; mso-border-top-alt: solid #4472C4 .5pt; mso-border-top-themecolor: accent1; padding: 0cm 5.4pt; width: 99.2pt;" width="132"><div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 0cm; mso-yfti-cnfc: 1; text-align: center;">
<b><span face=""arial" , sans-serif" style="color: white; font-size: 10pt;">Disability<o:p></o:p></span></b></div>
</td>
<td style="background: rgb(68, 114, 196); border-left: none; border: 1pt solid rgb(68, 114, 196); height: 27.9pt; mso-background-themecolor: accent1; mso-border-bottom-alt: solid #4472C4 .5pt; mso-border-bottom-themecolor: accent1; mso-border-right-alt: solid #4472C4 .5pt; mso-border-right-themecolor: accent1; mso-border-themecolor: accent1; mso-border-top-alt: solid #4472C4 .5pt; mso-border-top-themecolor: accent1; padding: 0cm 5.4pt; width: 99.25pt;" width="132"><div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 0cm; mso-yfti-cnfc: 1; text-align: center;">
<b><span face=""arial" , sans-serif" style="color: white; font-size: 10pt;">Exposure<o:p></o:p></span></b></div>
</td>
</tr>
<tr style="height: 20.5pt; mso-yfti-irow: 0;">
<td style="background: rgb(217, 226, 243); border-top: none; border: 1pt solid rgb(142, 170, 219); height: 20.5pt; mso-background-themecolor: accent1; mso-background-themetint: 51; mso-border-alt: solid #8EAADB .5pt; mso-border-themecolor: accent1; mso-border-themetint: 153; mso-border-top-alt: solid #8EAADB .5pt; mso-border-top-themecolor: accent1; mso-border-top-themetint: 153; padding: 0cm 5.4pt; width: 91.9pt;" width="123"><div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 0cm; mso-yfti-cnfc: 68; text-align: center;">
<span face=""arial" , sans-serif" style="color: #666666; font-size: 9pt;">Effort of breathing<o:p></o:p></span></div>
</td>
<td style="background: rgb(217, 226, 243); border-bottom: 1pt solid rgb(142, 170, 219); border-left: none; border-right: 1pt solid rgb(142, 170, 219); border-top: none; height: 20.5pt; mso-background-themecolor: accent1; mso-background-themetint: 51; mso-border-alt: solid #8EAADB .5pt; mso-border-bottom-themecolor: accent1; mso-border-bottom-themetint: 153; mso-border-left-alt: solid #8EAADB .5pt; mso-border-left-themecolor: accent1; mso-border-left-themetint: 153; mso-border-right-themecolor: accent1; mso-border-right-themetint: 153; mso-border-themecolor: accent1; mso-border-themetint: 153; mso-border-top-alt: solid #8EAADB .5pt; mso-border-top-themecolor: accent1; mso-border-top-themetint: 153; padding: 0cm 5.4pt; width: 120.5pt;" width="161"><div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 0cm; mso-yfti-cnfc: 64; text-align: center;">
<span face=""arial" , sans-serif" style="color: #666666; font-size: 9pt;">Heart rate<o:p></o:p></span></div>
</td>
<td style="background: rgb(217, 226, 243); border-bottom: 1pt solid rgb(142, 170, 219); border-left: none; border-right: 1pt solid rgb(142, 170, 219); border-top: none; height: 20.5pt; mso-background-themecolor: accent1; mso-background-themetint: 51; mso-border-alt: solid #8EAADB .5pt; mso-border-bottom-themecolor: accent1; mso-border-bottom-themetint: 153; mso-border-left-alt: solid #8EAADB .5pt; mso-border-left-themecolor: accent1; mso-border-left-themetint: 153; mso-border-right-themecolor: accent1; mso-border-right-themetint: 153; mso-border-themecolor: accent1; mso-border-themetint: 153; mso-border-top-alt: solid #8EAADB .5pt; mso-border-top-themecolor: accent1; mso-border-top-themetint: 153; padding: 0cm 5.4pt; width: 99.2pt;" width="132"><div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 0cm; mso-yfti-cnfc: 64; text-align: center;">
<span face=""arial" , sans-serif" style="color: #666666; font-size: 9pt;">Conscious level<o:p></o:p></span></div>
</td>
<td style="background: rgb(217, 226, 243); border-bottom: 1pt solid rgb(142, 170, 219); border-left: none; border-right: 1pt solid rgb(142, 170, 219); border-top: none; height: 20.5pt; mso-background-themecolor: accent1; mso-background-themetint: 51; mso-border-alt: solid #8EAADB .5pt; mso-border-bottom-themecolor: accent1; mso-border-bottom-themetint: 153; mso-border-left-alt: solid #8EAADB .5pt; mso-border-left-themecolor: accent1; mso-border-left-themetint: 153; mso-border-right-themecolor: accent1; mso-border-right-themetint: 153; mso-border-themecolor: accent1; mso-border-themetint: 153; mso-border-top-alt: solid #8EAADB .5pt; mso-border-top-themecolor: accent1; mso-border-top-themetint: 153; padding: 0cm 5.4pt; width: 99.25pt;" width="132"><div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 0cm; mso-yfti-cnfc: 64; text-align: center;">
<span face=""arial" , sans-serif" style="color: #666666; font-size: 9pt;">Fever<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: 1pt solid rgb(142, 170, 219); mso-border-alt: solid #8EAADB .5pt; mso-border-themecolor: accent1; mso-border-themetint: 153; mso-border-top-alt: solid #8EAADB .5pt; mso-border-top-themecolor: accent1; mso-border-top-themetint: 153; padding: 0cm 5.4pt; width: 91.9pt;" width="123"><div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 0cm; mso-yfti-cnfc: 4; text-align: center;">
<span face=""arial" , sans-serif" style="color: #666666; font-size: 9pt;">Respiratory rate<o:p></o:p></span></div>
<div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 0cm; mso-yfti-cnfc: 4; text-align: center;">
<span face=""arial" , sans-serif" style="color: #666666; font-size: 9pt;">and rhythm<o:p></o:p></span></div>
</td>
<td style="border-bottom: 1pt solid rgb(142, 170, 219); border-left: none; border-right: 1pt solid rgb(142, 170, 219); border-top: none; mso-border-alt: solid #8EAADB .5pt; mso-border-bottom-themecolor: accent1; mso-border-bottom-themetint: 153; mso-border-left-alt: solid #8EAADB .5pt; mso-border-left-themecolor: accent1; mso-border-left-themetint: 153; mso-border-right-themecolor: accent1; mso-border-right-themetint: 153; mso-border-themecolor: accent1; mso-border-themetint: 153; mso-border-top-alt: solid #8EAADB .5pt; mso-border-top-themecolor: accent1; mso-border-top-themetint: 153; padding: 0cm 5.4pt; width: 120.5pt;" width="161"><div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 0cm; text-align: center;">
<span face=""arial" , sans-serif" style="color: #666666; font-size: 9pt;">Pulse
volume<o:p></o:p></span></div>
</td>
<td style="border-bottom: 1pt solid rgb(142, 170, 219); border-left: none; border-right: 1pt solid rgb(142, 170, 219); border-top: none; mso-border-alt: solid #8EAADB .5pt; mso-border-bottom-themecolor: accent1; mso-border-bottom-themetint: 153; mso-border-left-alt: solid #8EAADB .5pt; mso-border-left-themecolor: accent1; mso-border-left-themetint: 153; mso-border-right-themecolor: accent1; mso-border-right-themetint: 153; mso-border-themecolor: accent1; mso-border-themetint: 153; mso-border-top-alt: solid #8EAADB .5pt; mso-border-top-themecolor: accent1; mso-border-top-themetint: 153; padding: 0cm 5.4pt; width: 99.2pt;" width="132"><div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 0cm; text-align: center;">
<span face=""arial" , sans-serif" style="color: #666666; font-size: 9pt;">Posture<o:p></o:p></span></div>
</td>
<td style="border-bottom: 1pt solid rgb(142, 170, 219); border-left: none; border-right: 1pt solid rgb(142, 170, 219); border-top: none; mso-border-alt: solid #8EAADB .5pt; mso-border-bottom-themecolor: accent1; mso-border-bottom-themetint: 153; mso-border-left-alt: solid #8EAADB .5pt; mso-border-left-themecolor: accent1; mso-border-left-themetint: 153; mso-border-right-themecolor: accent1; mso-border-right-themetint: 153; mso-border-themecolor: accent1; mso-border-themetint: 153; mso-border-top-alt: solid #8EAADB .5pt; mso-border-top-themecolor: accent1; mso-border-top-themetint: 153; padding: 0cm 5.4pt; width: 99.25pt;" width="132"><div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 0cm; text-align: center;">
<span face=""arial" , sans-serif" style="color: #666666; font-size: 9pt;">Rash<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="background: rgb(217, 226, 243); border-top: none; border: 1pt solid rgb(142, 170, 219); mso-background-themecolor: accent1; mso-background-themetint: 51; mso-border-alt: solid #8EAADB .5pt; mso-border-themecolor: accent1; mso-border-themetint: 153; mso-border-top-alt: solid #8EAADB .5pt; mso-border-top-themecolor: accent1; mso-border-top-themetint: 153; padding: 0cm 5.4pt; width: 91.9pt;" width="123"><div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 0cm; mso-yfti-cnfc: 68; text-align: center;">
<span face=""arial" , sans-serif" style="color: #666666; font-size: 9pt;">Stridor / wheeze<o:p></o:p></span></div>
</td>
<td style="background: rgb(217, 226, 243); border-bottom: 1pt solid rgb(142, 170, 219); border-left: none; border-right: 1pt solid rgb(142, 170, 219); border-top: none; mso-background-themecolor: accent1; mso-background-themetint: 51; mso-border-alt: solid #8EAADB .5pt; mso-border-bottom-themecolor: accent1; mso-border-bottom-themetint: 153; mso-border-left-alt: solid #8EAADB .5pt; mso-border-left-themecolor: accent1; mso-border-left-themetint: 153; mso-border-right-themecolor: accent1; mso-border-right-themetint: 153; mso-border-themecolor: accent1; mso-border-themetint: 153; mso-border-top-alt: solid #8EAADB .5pt; mso-border-top-themecolor: accent1; mso-border-top-themetint: 153; padding: 0cm 5.4pt; width: 120.5pt;" width="161"><div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 0cm; mso-yfti-cnfc: 64; text-align: center;">
<span face=""arial" , sans-serif" style="color: #666666; font-size: 9pt;">Capillary refill<o:p></o:p></span></div>
</td>
<td style="background: rgb(217, 226, 243); border-bottom: 1pt solid rgb(142, 170, 219); border-left: none; border-right: 1pt solid rgb(142, 170, 219); border-top: none; mso-background-themecolor: accent1; mso-background-themetint: 51; mso-border-alt: solid #8EAADB .5pt; mso-border-bottom-themecolor: accent1; mso-border-bottom-themetint: 153; mso-border-left-alt: solid #8EAADB .5pt; mso-border-left-themecolor: accent1; mso-border-left-themetint: 153; mso-border-right-themecolor: accent1; mso-border-right-themetint: 153; mso-border-themecolor: accent1; mso-border-themetint: 153; mso-border-top-alt: solid #8EAADB .5pt; mso-border-top-themecolor: accent1; mso-border-top-themetint: 153; padding: 0cm 5.4pt; width: 99.2pt;" width="132"><div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 0cm; mso-yfti-cnfc: 64; text-align: center;">
<span face=""arial" , sans-serif" style="color: #666666; font-size: 9pt;">Pupils<o:p></o:p></span></div>
</td>
<td style="background: rgb(217, 226, 243); border-bottom: 1pt solid rgb(142, 170, 219); border-left: none; border-right: 1pt solid rgb(142, 170, 219); border-top: none; mso-background-themecolor: accent1; mso-background-themetint: 51; mso-border-alt: solid #8EAADB .5pt; mso-border-bottom-themecolor: accent1; mso-border-bottom-themetint: 153; mso-border-left-alt: solid #8EAADB .5pt; mso-border-left-themecolor: accent1; mso-border-left-themetint: 153; mso-border-right-themecolor: accent1; mso-border-right-themetint: 153; mso-border-themecolor: accent1; mso-border-themetint: 153; mso-border-top-alt: solid #8EAADB .5pt; mso-border-top-themecolor: accent1; mso-border-top-themetint: 153; padding: 0cm 5.4pt; width: 99.25pt;" width="132"><div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 0cm; mso-yfti-cnfc: 64; text-align: center;">
<span face=""arial" , sans-serif" style="color: #666666; font-size: 9pt;">Bruising<o:p></o:p></span></div>
</td>
</tr>
<tr style="height: 3.5pt; mso-yfti-irow: 3;">
<td style="border-top: none; border: 1pt solid rgb(142, 170, 219); height: 3.5pt; mso-border-alt: solid #8EAADB .5pt; mso-border-themecolor: accent1; mso-border-themetint: 153; mso-border-top-alt: solid #8EAADB .5pt; mso-border-top-themecolor: accent1; mso-border-top-themetint: 153; padding: 0cm 5.4pt; width: 91.9pt;" width="123"><div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 0cm; mso-yfti-cnfc: 4; text-align: center;">
<span face=""arial" , sans-serif" style="color: #666666; font-size: 9pt;">Auscultation<o:p></o:p></span></div>
</td>
<td style="border-bottom: 1pt solid rgb(142, 170, 219); border-left: none; border-right: 1pt solid rgb(142, 170, 219); border-top: none; height: 3.5pt; mso-border-alt: solid #8EAADB .5pt; mso-border-bottom-themecolor: accent1; mso-border-bottom-themetint: 153; mso-border-left-alt: solid #8EAADB .5pt; mso-border-left-themecolor: accent1; mso-border-left-themetint: 153; mso-border-right-themecolor: accent1; mso-border-right-themetint: 153; mso-border-themecolor: accent1; mso-border-themetint: 153; mso-border-top-alt: solid #8EAADB .5pt; mso-border-top-themecolor: accent1; mso-border-top-themetint: 153; padding: 0cm 5.4pt; width: 120.5pt;" width="161"><div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 0cm; text-align: center;">
<span face=""arial" , sans-serif" style="color: #666666; font-size: 9pt;">Skin
temperature<o:p></o:p></span></div>
</td>
<td style="border-bottom: 1pt solid rgb(142, 170, 219); border-left: none; border-right: 1pt solid rgb(142, 170, 219); border-top: none; height: 3.5pt; mso-border-alt: solid #8EAADB .5pt; mso-border-bottom-themecolor: accent1; mso-border-bottom-themetint: 153; mso-border-left-alt: solid #8EAADB .5pt; mso-border-left-themecolor: accent1; mso-border-left-themetint: 153; mso-border-right-themecolor: accent1; mso-border-right-themetint: 153; mso-border-themecolor: accent1; mso-border-themetint: 153; mso-border-top-alt: solid #8EAADB .5pt; mso-border-top-themecolor: accent1; mso-border-top-themetint: 153; padding: 0cm 5.4pt; width: 99.2pt;" width="132"></td>
<td style="border-bottom: 1pt solid rgb(142, 170, 219); border-left: none; border-right: 1pt solid rgb(142, 170, 219); border-top: none; height: 3.5pt; mso-border-alt: solid #8EAADB .5pt; mso-border-bottom-themecolor: accent1; mso-border-bottom-themetint: 153; mso-border-left-alt: solid #8EAADB .5pt; mso-border-left-themecolor: accent1; mso-border-left-themetint: 153; mso-border-right-themecolor: accent1; mso-border-right-themetint: 153; mso-border-themecolor: accent1; mso-border-themetint: 153; mso-border-top-alt: solid #8EAADB .5pt; mso-border-top-themecolor: accent1; mso-border-top-themetint: 153; padding: 0cm 5.4pt; width: 99.25pt;" width="132"></td>
</tr>
<tr>
<td style="background: rgb(217, 226, 243); border-top: none; border: 1pt solid rgb(142, 170, 219); mso-background-themecolor: accent1; mso-background-themetint: 51; mso-border-alt: solid #8EAADB .5pt; mso-border-themecolor: accent1; mso-border-themetint: 153; mso-border-top-alt: solid #8EAADB .5pt; mso-border-top-themecolor: accent1; mso-border-top-themetint: 153; padding: 0cm 5.4pt; width: 91.9pt;" width="123"><div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 0cm; mso-yfti-cnfc: 68; text-align: center;">
<span face=""arial" , sans-serif" style="color: #666666; font-size: 9pt;">Skin colour<o:p></o:p></span></div>
</td>
<td style="background: rgb(217, 226, 243); border-bottom: 1pt solid rgb(142, 170, 219); border-left: none; border-right: 1pt solid rgb(142, 170, 219); border-top: none; mso-background-themecolor: accent1; mso-background-themetint: 51; mso-border-alt: solid #8EAADB .5pt; mso-border-bottom-themecolor: accent1; mso-border-bottom-themetint: 153; mso-border-left-alt: solid #8EAADB .5pt; mso-border-left-themecolor: accent1; mso-border-left-themetint: 153; mso-border-right-themecolor: accent1; mso-border-right-themetint: 153; mso-border-themecolor: accent1; mso-border-themetint: 153; mso-border-top-alt: solid #8EAADB .5pt; mso-border-top-themecolor: accent1; mso-border-top-themetint: 153; padding: 0cm 5.4pt; width: 120.5pt;" width="161"></td>
<td style="background: rgb(217, 226, 243); border-bottom: 1pt solid rgb(142, 170, 219); border-left: none; border-right: 1pt solid rgb(142, 170, 219); border-top: none; mso-background-themecolor: accent1; mso-background-themetint: 51; mso-border-alt: solid #8EAADB .5pt; mso-border-bottom-themecolor: accent1; mso-border-bottom-themetint: 153; mso-border-left-alt: solid #8EAADB .5pt; mso-border-left-themecolor: accent1; mso-border-left-themetint: 153; mso-border-right-themecolor: accent1; mso-border-right-themetint: 153; mso-border-themecolor: accent1; mso-border-themetint: 153; mso-border-top-alt: solid #8EAADB .5pt; mso-border-top-themecolor: accent1; mso-border-top-themetint: 153; padding: 0cm 5.4pt; width: 99.2pt;" width="132"></td>
<td style="background: rgb(217, 226, 243); border-bottom: 1pt solid rgb(142, 170, 219); border-left: none; border-right: 1pt solid rgb(142, 170, 219); border-top: none; mso-background-themecolor: accent1; mso-background-themetint: 51; mso-border-alt: solid #8EAADB .5pt; mso-border-bottom-themecolor: accent1; mso-border-bottom-themetint: 153; mso-border-left-alt: solid #8EAADB .5pt; mso-border-left-themecolor: accent1; mso-border-left-themetint: 153; mso-border-right-themecolor: accent1; mso-border-right-themetint: 153; mso-border-themecolor: accent1; mso-border-themetint: 153; mso-border-top-alt: solid #8EAADB .5pt; mso-border-top-themecolor: accent1; mso-border-top-themetint: 153; padding: 0cm 5.4pt; width: 99.25pt;" width="132"></td>
</tr>
</tbody></table>
</h4>
<h4 style="text-align: left;">
Airway</h4>
Children are respiratory creatures.<br />
<div style="text-align: left;">
</div>
Assess Patency<br />
Vocalisations<br />
<div>
<br />
Airway anatomical challenges<br />
<ul style="text-align: left;">
<li>2 big: head, tongue</li>
<li>2 small: narrow easily blocked nasal airways, narrow cricoid,</li>
<li>2 short: airway (depth = 3 x ett), time to desaturation (less reserve)</li>
<li>2 tall: epiglotis/floppy, think tall (prepare, pep talk, pee)</li>
</ul>
<br />
Should aim to: Resuscitate before you intubate (if maintaining oxygenation & ventilation)<br />
<br />
<h4 style="text-align: left;">
Breathing</h4>
<div style="text-align: left;">
Respiratory Rate<br />
Work of Breathing: Sounds & HOUNDS<br />
Chest Auscultation<br />
Pulse oximetry (check waveform as well)<br />
<br /></div>
<h4 style="text-align: left;">
Ciruclation</h4>
<div style="text-align: left;">
Heart Rate, Pulse Volume & Blood Pressure</div>
<ul style="text-align: left;">
<li>Bradycardia and/or hypotension are OMINOUS, LATE SIGNS.</li>
<li>Stroke volume small and fixed in infants, CO more dependant on HR. SV has a greater role with age.</li>
<li>Comparing peripheral and central pulse volume may provide help with early detection.</li>
</ul>
PCPC (pallor, delayed cap refill, petechiae, cyanosis, mottling)<br />
Think End organ perfusion: e.g. skin temperature, altered mental state, urine output.<br />
<br />
Features Suggestive of Cardiac Failure<br />
<ul style="text-align: left;">
<li>Cyanosis, not correcting with O2 therapy.</li>
<li>Tachycardia out of proportion to respiratory difficulty</li>
<li>Raised JVP</li>
<li>Gallop rhythm/murmur</li>
<li>Hepatomegaly</li>
<li>Absent femoral pulses</li>
</ul>
<br />
<div style="text-align: left;">
Cold shock = adrenaline (children typically)<br />
Warm shock = noradrenaline<br />
<br /></div>
<h4 style="text-align: left;">
Disability</h4>
In Paediatric Emergencies AVPU provides a quick a succinct method to gauge level of consciousness.<br />
<ul style="text-align: left;">
<li>A lert</li>
<li>V oice</li>
<li>P ain</li>
<li>U nresponsive</li>
</ul>
<br />
An age appropriate Paediatric-modified GCS could be calculated at a later date.<br />
<br />
Posture<br />
<ul style="text-align: left;">
<li>Most children with a serious illness are floppy</li>
<li>Stiff posturing suggests severe brain dysfunction</li>
</ul>
<br />
Pupils<br />
Convulsions<br />
BSL<br />
<br />
<h4 style="text-align: left;">
Exposure</h4>
<div>
<div>
Swift head to toe observation of the child. Formal head-toe examination, should be part of your Secondary Assessment.<br />
<br /></div>
<div>
Temperature</div>
<div>
<ul style="text-align: left;">
<li>Check for fever</li>
<li>Maintain Normothermia. Infants lose heat faster.</li>
</ul>
</div>
<div>
Rashes</div>
<div>
Bruising</div>
<div>
<br /></div>
</div>
<h4 style="text-align: left;">
Fluid Status</h4>
<b>Hydration Status</b><br />
<div align="center">
<table border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="background: white; border-collapse: collapse; mso-padding-alt: 1.5pt 1.5pt 1.5pt 1.5pt; mso-yfti-tbllook: 1184;">
<tbody>
<tr>
<td style="padding: 0cm;"><div class="MsoNormal" style="line-height: normal; margin-bottom: 0cm;">
Moderate
dehydration (4-6%) <o:p></o:p></div>
</td>
<td style="padding: 0cm; width: 233.1pt;" width="311"><div class="MsoNormal" style="line-height: normal; margin-bottom: 0cm;">
Severe
dehydration (>/= 7%)<o:p></o:p></div>
</td>
</tr>
<tr>
<td style="padding: 0cm;"><ul type="disc">
<li class="MsoNormal" style="line-height: normal; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"> Delayed
CRT<br />
(Central Capillary Refill Time) > 2 secs<o:p></o:p></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;">Increased
respiratory rate<o:p></o:p></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;">Mild
decreased tissue turgor<o:p></o:p></li>
</ul>
</td>
<td style="padding: 0cm; width: 233.1pt;" width="311"><ul type="disc">
<li class="MsoNormal" style="line-height: normal; mso-list: l1 level1 lfo2; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;">Very
delayed CRT > 3 secs, mottled skin<o:p></o:p></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l1 level1 lfo2; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;">Other
signs of shock (tachycardia, irritable or reduced conscious level,
hypotension)<o:p></o:p></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l1 level1 lfo2; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;">Deep,
acidotic breathing<o:p></o:p></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l1 level1 lfo2; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;">Decreased
tissue turgor<o:p></o:p></li>
</ul>
</td>
</tr>
</tbody></table>
</div>
<div style="text-align: left;">
<b>Inputs/Outputs</b></div>
<div style="text-align: left;">
Think about what has gone into the child in terms of fluid (whether oral, IV or other) and what has and will be lost (e.g. diarrhoea, vomiting).</div>
<div style="text-align: left;">
<br /></div>
<h3 style="text-align: left;">
Secondary Assessment</h3>
See Approach to the Seriously Ill Child - part 2 (still to come).<br />
<br />
<h3 style="text-align: left;">
Stabilisation and Transfer to Definitive Care</h3>
See Approach to the Seriously Ill Child - part 2 (still to come).<br />
<br />
<h3 style="text-align: left;">
Advanced Life Support</h3>
Hopefully with early detection and management you avoid your patient having a Cardiac Arrest. But there is always a possible that they will or that's how they will arrive. Below is a flowchart summarizing the principles of Paediatric Advanced Life Support.<br />
<br />
For more details see the Australian Resuscitation Council Guidelines at <a href="https://resus.org.au/guidelines/">resus.org.au/guidelines</a>.<br />
<br />
<div class="separator" style="clear: both; text-align: left;">
<a href="https://2.bp.blogspot.com/-2mrW-qU-evU/W2WNLGFX8LI/AAAAAAAADTo/fsQ226bsrvsJ_f3-Z7JgZ5BK6IBH8FbugCLcBGAs/s1600/PALS%2B-%2BExtended%2B600x.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="800" data-original-width="600" src="https://2.bp.blogspot.com/-2mrW-qU-evU/W2WNLGFX8LI/AAAAAAAADTo/fsQ226bsrvsJ_f3-Z7JgZ5BK6IBH8FbugCLcBGAs/s1600/PALS%2B-%2BExtended%2B600x.png" /></a></div>
<h3 style="text-align: left;">
Further Resources & References</h3>
<div>
<ul style="text-align: left;">
<li><b>RCH: Clinical Guide </b><a href="https://www.rch.org.au/clinicalguide/guideline_index/">www.rch.org.au/clinicalguide/guideline_index/</a></li>
<li><b>NSW Rural Emergency Paediatric Guidelines </b><a href="https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2014_007.pdf">www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2014_007.pdf</a></li>
<li><b>NSW Health Guidelines </b><a href="https://www.ciap.health.nsw.gov.au/browse/paed.html">www.ciap.health.nsw.gov.au/browse/paed.html</a></li>
<li><b>Emergency Care Institute </b><a href="http://emergencyprotocols.org.au/wp-content/uploads/2018/05/EmergencyProtocols_Paediatric.pdf">emergencyprotocols.org.au/wp-content/uploads/2018/05/EmergencyProtocols_Paediatric.pdf</a></li>
<li><b>Advanced Paediatric Life Support - 6th Edition</b></li>
<li><b>Paediatric BASIC - version 1.2 (2015)</b></li>
<li><b>Australian Resuscitation Council </b><a href="http://www.resus.org.au/">www.resus.org.au</a></li>
</ul>
</div>
</div>
</div>
Aaron Sparshotthttp://www.blogger.com/profile/16868086818074290497noreply@blogger.com0tag:blogger.com,1999:blog-4281944981424326587.post-47528259317136767182018-07-19T10:32:00.003+10:002018-11-09T12:35:01.749+10:00REM: Snake Bite / Envenomation<div dir="ltr" style="text-align: left;" trbidi="on">
<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="separator" style="clear: both; text-align: center;">
<a href="https://3.bp.blogspot.com/-B_afsfSu6nk/W0tHczy-5zI/AAAAAAAADSs/msKXk2IfCIADUjrYQotn5RdpvGlYlkYWACLcBGAs/s1600/snake.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1067" data-original-width="1600" height="1" src="https://3.bp.blogspot.com/-B_afsfSu6nk/W0tHczy-5zI/AAAAAAAADSs/msKXk2IfCIADUjrYQotn5RdpvGlYlkYWACLcBGAs/s640/snake.jpg" width="1" /></a></div>
Snake bites are a potential medical emergency even though the majority do not involve significant envenomation. The role of the clinician in these circumstances is working out which patients have been envenomated, and the select group of patient which require anti-venom.<br />
<br />
Appropriate and timely action of first aid principles are fundamental in reducing the morbidity and mortality associated with snake bites.<br />
<br />
This is part of the <a href="http://www.ivline.org/2018/06/acrrm-emergency-medicine-study-guide.html">Rural Emergency Module</a> series (designed in particular for ACRRM Trainees).<br />
<br />
<div dir="ltr" style="text-align: left;" trbidi="on">
<table border="0" cellpadding="0" cellspacing="0" class="MsoTableGrid" style="border-collapse: collapse; border: none; mso-border-insideh: none; mso-border-insidev: none; mso-padding-alt: 0cm 5.4pt 0cm 5.4pt; mso-yfti-tbllook: 1184;">
<tbody>
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<b style="mso-bidi-font-weight: normal;"><span style="color: #ffc000; mso-themecolor: accent4;">Initial Assessment
and Management<o:p></o:p></span></b></h2>
</td>
</tr>
</tbody></table>
<br />
<span style="color: orange;"><b>Recognise</b></span><br />
<ul style="text-align: left;">
<li><span style="color: orange;">Recognise, send for help, gather resources and appropriate equipment.</span></li>
<li><span style="color: orange;">Move to appropriate area monitoring area.</span></li>
<li><span style="color: orange;">Monitoring - HR, BP, RR, SpO2, Telemetry/Cardiac Monitoring (if available)</span></li>
<li><span style="color: orange;">Identify snake if possible & avoid further envenomation by the assailant snake.</span></li>
<li><span style="color: orange;">Apply immediate first aid principles and Pressure Immobilisation Bandage (see below) and keep the patient immobilised/still.</span></li>
<li><span style="color: orange;">Ensure anti-venom available.</span></li>
<li><span style="color: orange;">Liaise with a toxicologist as indicated.</span></li>
</ul>
<span style="color: orange;"><br /></span>
<span style="color: orange;"><b>Airway</b>:</span><br />
<ul style="text-align: left;">
<li><span style="color: orange;">Assess for patency and protection</span></li>
<li><span style="color: orange;">Intubate if respiratory failure or distress</span></li>
</ul>
<span style="color: orange;"><b>Breathing</b>:</span><br />
<ul style="text-align: left;">
<li><span style="color: orange;">Assess depth of breathing and respiratory rate, SpO2 + ETCO2 monitoring</span></li>
<li><span style="color: orange;">Correct Hypoxia - SpO2 >93% in patients with no underlying lung condition</span></li>
</ul>
<span style="color: orange;"><b>Circulation</b>:</span><br />
<ul style="text-align: left;">
<li><span style="color: orange;">Establish IVC Access: Place in at least 1 IVC on non-affected limb for bloods.</span></li>
<li><span style="color: orange;">2nd IVC should be established if unstable or likely to give Anti-venom.</span></li>
<li><span style="color: orange;">Assess for bleeding from potential bite site, mucous membranes and IVC sites</span></li>
<li><span style="color: orange;">Commence with IV fluid. Be mindful of fluid overload. Consider appropriate IV Fluid therapy in Rhadomyolysis and acute renal failure.</span></li>
</ul>
<span style="color: orange;"><b>Disability</b>:</span><br />
<ul style="text-align: left;">
<li><span style="color: orange;">GCS / AVPU</span></li>
<li><span style="color: orange;">BSL</span></li>
<li><span style="color: orange;">Assess for signs of flaccid paralysis, cranial nerve deficits, ptosis</span></li>
</ul>
<span style="color: orange;"><b>Exposure</b>:</span><br />
<ul style="text-align: left;">
<li><span style="color: orange;">Check temperature, maintain normothermia</span></li>
<li><span style="color: orange;">Urine dipstick - check for haematuria and can be used for Snake Venom Detection as well.</span></li>
<li><span style="color: orange;">Assess for myolysis: muscle pain, tenderness or weakness</span></li>
</ul>
<br />
<div>
<b><span style="color: orange;">Pressure Immbolisation Bandage</span></b><br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://1.bp.blogspot.com/-muHyoV-pMEs/W0_X4sZzx-I/AAAAAAAADS8/KgZByluMmD09rv8-bgHIH5fwYRbCwW09gCLcBGAs/s1600/PIB%2B-%2BEnvenomation.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="225" data-original-width="600" src="https://1.bp.blogspot.com/-muHyoV-pMEs/W0_X4sZzx-I/AAAAAAAADS8/KgZByluMmD09rv8-bgHIH5fwYRbCwW09gCLcBGAs/s1600/PIB%2B-%2BEnvenomation.jpg" /></a></div>
<div class="separator" style="clear: both; text-align: center;">
<span style="color: orange; font-size: x-small;">Wikihow: Pressure Immobilisation Bandage</span></div>
<br /></div>
<br />
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<td style="background: #4472C4; height: 20.45pt; mso-background-themecolor: accent1; padding: 0cm 5.4pt 0cm 5.4pt; width: 450.8pt;" valign="top" width="601"><h2 style="line-height: normal; mso-outline-level: 2;">
<b style="mso-bidi-font-weight: normal;"><span style="color: #222a35; mso-themecolor: text2; mso-themeshade: 128;">History</span><o:p></o:p></b></h2>
</td>
</tr>
</tbody></table>
<br />
<b><span style="color: #0b5394;">Signs/symptoms</span></b><br />
<ul style="text-align: left;">
<li><span style="color: #0b5394;">Evidence of a bite</span></li>
<li><span style="color: #0b5394;">Abnormal Bleeding</span></li>
<li><span style="color: #0b5394;">Evidence of descending symmetrical flaccid paralysis</span></li>
<li><span style="color: #0b5394;">Lymphadenopathy</span></li>
<li><span style="color: #0b5394;">Collapse / loss of consciousness</span></li>
<li><span style="color: #0b5394;">Nausea, vomiting, diaphoresis</span></li>
<li><span style="color: #0b5394;">Headache, ptosis</span></li>
<li><span style="color: #0b5394;">Abdominal pain, diarrhoea</span></li>
<li><span style="color: #0b5394;">Myalgias</span></li>
</ul>
<b><span style="color: #0b5394;">Allergies</span></b><br />
<b><span style="color: #0b5394;">Meds </span></b><br />
<ul style="text-align: left;">
<li><span style="color: #0b5394;">Anticoagulants, anti-platelets </span></li>
</ul>
<b style="color: #0b5394;">PMHx</b><span style="color: #0b5394;">: </span><br />
<ul style="text-align: left;">
<li><span style="color: #0b5394;">Previous envenomation and/or exposure to antivenom</span></li>
<li><span style="color: #0b5394;">Asthma</span></li>
<li><span style="color: #0b5394;">Auto-immune disorders</span></li>
<li><span style="color: #0b5394;">Renal or Cardiovascular disease</span></li>
</ul>
<b><span style="color: #0b5394;">Last oral intake</span></b><br />
<b><span style="color: #0b5394;">Events</span></b><br />
<ul style="text-align: left;">
<li><span style="color: #0b5394;">Time and circumstances of snake bite</span></li>
<li><span style="color: #0b5394;">Was the snake seen, and any identifying factors of the snake (typically low-yield) - more useful if pet or snake handler</span></li>
<li><span style="color: #0b5394;">Number of strikes</span></li>
<li><span style="color: #0b5394;">First aid and PIB applied.</span></li>
</ul>
<br />
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<b style="mso-bidi-font-weight: normal;"><span style="color: #ff33ff;">Investigations</span></b><b style="mso-bidi-font-weight: normal;"><span style="color: #5f0272;"><o:p></o:p></span></b></h2>
</td>
</tr>
</tbody></table>
<br />
<ul style="text-align: left;">
<li><span style="color: purple;">PoC Bloods typically unreliable and not recommended </span></li>
<li><span style="color: purple;">INR, APPT, fibrinogen, D-dimer, </span></li>
<li><span style="color: purple;">FBC, U&Es, Ck</span></li>
<li><span style="color: purple;">Snake Venom Detection Kit (can be used in conjunction with clinical + geographical information)</span></li>
<li><span style="color: purple;">Urine dipstick</span></li>
</ul>
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<b style="mso-bidi-font-weight: normal;"><span style="color: #009242;">Management<o:p></o:p></span></b></h2>
</td>
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</tbody></table>
</div>
</div>
<br />
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<h4 style="clear: both; text-align: left;">
Snake Antivenom</h4>
<div>
Snake anti-venom is the key treatment to managing significant evenomation and it's associated complications.</div>
<div class="separator" style="clear: both; text-align: left;">
</div>
<ul style="text-align: left;">
<li><b>Indications</b>: evidence of significant systemic evenomation (clinical or laboratory)</li>
<ul>
<li>neurotoxic paralysis</li>
<li>coagulopathy</li>
<li>myotoxicity</li>
<li>acute renal impairment / failure</li>
<li>collapse and/or seizures</li>
</ul>
<li><b>Contraindications</b></li>
<ul>
<li>Nil absolute</li>
<li>Increased risk of anaphylaxis in those previously treated with anti-venom</li>
</ul>
<li><b>Timing</b>:</li>
<ul>
<li>Efficacy is improved with early administration, once envenomation has been identified.</li>
<li>Risks of administrating anti-venom >24hrs post initial bite, may be greater than the risks of envenomation. Seek expert advice.</li>
</ul>
<li><b>Choice</b>:</li>
<ul>
<li>Monovalent anti-venom is the preferred choice.</li>
<li>One vial of antivenom is now recommended to treat children and adults for all snake types.</li>
<li>The Australian Polyvalent snake venom will cover the 5 most common snake venom immunotypes in Australia and PNG. Increased risk of hypersensitivity reactions.</li>
</ul>
<li><b>Administration</b>: </li>
<ul>
<li>All patient should recieve at least 1 dose of anti-venom if indicated. Further doses may be required dependent on snake, and assessed level of envenomation. Please see Clinician's Guide to Bite and Stings for more details.</li>
<li>Be prepared to treat anaphylaxis</li>
<li>Administer 1 ampoule diluted in 500ml of 0.9% saline IV over 20 minutes. In children aim to keep total volume less than 10 mL/kg.</li>
<li>Antivenom maybe given as a rapid IV push if the patient is unstable or in cardiac arrest</li>
</ul>
<li><b>Adverse drug reactions</b>:</li>
<ul>
<li>Anaphylaxis</li>
<li>Serum Sickness</li>
</ul>
</ul>
<div>
<br /></div>
<h4 style="clear: both; text-align: left;">
Supportive Cares</h4>
<ul style="text-align: left;">
<li><b>Fluid therapy and feeding</b>: A Crystalloid is appropriate for the majority of patients. In potential life-threatening bleeds the use of FFP is reasonable. Limit oral intake initially to minimize risk of venom-induced vomiting causing aspiration pneumonia.</li>
<li><b>Analgesia, Antiemetic</b>: Most patients with snake bite will not have significant pain. Simple analgesia should be sufficient. If pain is increasing it may indicate myolysis which requires reassessment. Narcotics should be avoided to minimize respiratory depression.<br />Anti-emetics can be useful in avoiding emesis and potential aspiration pneumonia, and also for patient comfort.</li>
<li><b>Antibiotics</b>: Antibiotics are not routinely required as secondary infection from Australian snakes is uncommon. Tetanus immunity should be updated, once coagulopathy has been resolved.</li>
<li><b>Sedation</b>: typically wish to avoid sedating the patient. This includes the use of sedating anti-histamines. Sedation only for intubation purposes.</li>
<li><b>Thromboprophylaxis</b>: not required.</li>
<li><b>Head up position</b>: nil particular position is mandated. </li>
<li><b>Ulcer prophylaxis</b>: not routinely required.</li>
<li><b>Glucose control</b>: maintain normoglycaemia 5-12 mmol.</li>
<li><b>Skin/eye care and suctioning</b>: routine cares, monitor for signs of bleeding</li>
<li><b>Indwelling catheter</b>: typically not required, but can be useful for monitoring urine output.</li>
<li><b>Nasogastric tube</b>: typically not required, and mostly should be avoided.</li>
<li><b>Bowel cares</b>: routine.</li>
<li><b>Environment</b>: Maintain normothermia. Keep patient or transfer patient to a monitored environment, with access to onsite pathology.</li>
<li><b>De-escalation</b> (e.g. end of life issues, treatments no longer needed)</li>
<li><b>Psychosocial support</b> (for patient, family and staff)</li>
</ul>
<div>
<br /></div>
<h3 style="text-align: left;">
<span style="color: #444444;">References/Further Resources</span></h3>
<div>
<ul style="text-align: left;">
<li><b><span style="color: #444444;">LifeintheFastLane</span></b></li>
<ul>
<li><span style="color: #444444;">Approach to Snake Bite: <a href="https://lifeinthefastlane.com/tox-library/basics/approach-to-snakebite/">https://lifeinthefastlane.com/tox-library/basics/approach-to-snakebite/</a></span></li>
</ul>
<li><b><span style="color: #444444;">Clinician's Guide to Venomous Bites and Stings</span></b></li>
<ul>
<li><a href="http://www.toxinology.com/generic_static_files/A%20Clinician's%20Guide%20to%20Venomous%20Bites%20&%20Stings%202013.pdf"><span style="color: #444444;">http://www.toxinology.com/generic_static_files/A%20Clinician's%20Guide%20to%20Venomous%20Bites%20&%20Stings%202013.pdf</span></a></li>
</ul>
<li><b><span style="color: #444444;">Victorian Emergency Care Clinical Network</span></b></li>
<ul>
<li><span style="color: #444444;">Management of Snake Bite: <a href="https://www2.health.vic.gov.au/Api/downloadmedia/%7B99261003-5645-4537-90C8-699DDC3C22FF%7D">https://www2.health.vic.gov.au/Api/downloadmedia/%7B99261003-5645-4537-90C8-699DDC3C22FF%7D</a></span></li>
</ul>
<li><b><span style="color: #444444;">Presentation: Snakebite, Now What? </span></b></li>
<ul>
<li><a href="https://www.slideshare.net/precordialthump/snakebite-now-what"><span style="color: #444444;">https://www.slideshare.net/precordialthump/snakebite-now-what</span></a></li>
</ul>
</ul>
</div>
</div>
Aaron Sparshotthttp://www.blogger.com/profile/16868086818074290497noreply@blogger.com0tag:blogger.com,1999:blog-4281944981424326587.post-49004354852943392162018-07-09T23:05:00.002+10:002018-07-09T23:05:29.589+10:00REM: Seizure / Epilepsy<div dir="ltr" style="text-align: left;" trbidi="on">
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Seizures are defined as<i> excessive, abnormal cortical neuronal activity resulting in a variety of physical symptoms</i>. Seizures / convulsions persisting beyond 5 minutes can be thought to be Status Epilepticus, and increase the risk of complications (including death) to the individual. Status Epilepticus has a higher mortality in Adults than it does in Children.<br />
<br />
Treatment is aimed at terminating the seizure as soon as possible, identifying cause, maintenance of ABCs, and avoiding/minimizing complications where possible.<br />
<br />
This is part of the <a href="http://www.ivline.org/2018/06/acrrm-emergency-medicine-study-guide.html">Rural Emergency Module</a> series (designed in particular for ACRRM Trainees).<br />
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<b style="mso-bidi-font-weight: normal;"><span style="color: #ffc000; mso-themecolor: accent4;">Initial Assessment
and Management<o:p></o:p></span></b></h2>
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<br />
<b><span style="color: #e69138;">Recognition</span></b><br />
<ul style="text-align: left;">
<li><span style="color: #e69138;">Recognise, send for help, gather resources and appropriate equipment. </span></li>
<li><span style="color: #e69138;">Protect patient and self from further danger.</span></li>
<li><span style="color: #e69138;">Move to resuscitation bay, when safe to do so.</span></li>
<li><span style="color: #e69138;">Monitoring.</span></li>
</ul>
<span style="color: #e69138;">Generalized status epilepticus is currently defined as either:</span><br />
<ul style="text-align: left;">
<li><span style="color: #e69138;">Ongoing convulsive seizure > 5 minutes</span></li>
<li><span style="color: #e69138;">Recurrent seizures without normalization of consciousness between seizures.</span></li>
</ul>
<br />
<span style="color: #e69138;"></span><br />
<span style="color: #e69138;"><b>Airway</b>:</span><br />
<ul style="text-align: left;">
<li><span style="color: #e69138;">Check airway. </span></li>
<li><span style="color: #e69138;">Manage airway with recovery position, airway adjuncts and intubation if required.</span></li>
<li><span style="color: #e69138;">Give oxygen as indicated.</span></li>
<li><span style="color: #e69138;">Suction for secretions. Clear vomitus.</span></li>
<li><span style="color: #e69138;">C-Spine precautions (only if trauma suspected)</span></li>
</ul>
<span style="color: #e69138;"><b>Breathing</b>:</span><br />
<ul style="text-align: left;">
<li><span style="color: #e69138;">If breathing is inadequate, assist with BVM + high flow oxygen (prone to hypercapnia)</span></li>
<li><span style="color: #e69138;">Place on at least some Nasal Prongs / NRB mask initially.</span></li>
<li><span style="color: #e69138;">Avoid hypoxia.</span></li>
</ul>
<span style="color: #e69138;"><b>Circulation</b><span style="color: #e69138;">:</span></span><br />
<ul style="text-align: left;">
<li><span style="color: #e69138;">Early access – PIVC or IO</span></li>
<li><span style="color: #e69138;">IV fluid line (primed and ready to go)</span></li>
</ul>
<span style="color: #e69138;"><b>Disability</b>:</span><br />
<ul style="text-align: left;">
<li><span style="color: #e69138;">Level of consciousness – GCS, AVPU</span></li>
<li><span style="color: #e69138;">Check BSL</span></li>
<li><span style="color: #e69138;">Focal neurology</span></li>
<li><span style="color: #e69138;">Pupil response</span></li>
<li><span style="color: #e69138;">Meningism</span></li>
<li><span style="color: #e69138;">Lateral tongue biting</span></li>
</ul>
<span style="color: #e69138;"><b>Exposure</b>:</span><br />
<ul style="text-align: left;">
<li><span style="color: #e69138;">Check temp, maintain Normothermia.</span></li>
<li><span style="color: #e69138;">Reminder to check bedside BSL + VBG if able</span></li>
<li><span style="color: #e69138;">Correct electrolyte disturbances</span></li>
</ul>
<br />
<span style="color: #e69138;"><br /></span>
<b><span style="color: #e69138;">Terminate Seizure</span></b><br />
<ul style="text-align: left;">
<li><span style="color: #e69138;">First Line: Benzodiazepines – Bolus dose, route dependent on ease and drug choice</span></li>
<li><span style="color: #e69138;">Second Line: usually require intubation + mechanical ventilation.</span></li>
<ul>
<li><span style="color: #e69138;">IV Phenytoin: 15-20 mg/kg IV over 30 minutes or longer</span></li>
<li><span style="color: #e69138;">IV Sodium Valproate: 40 mg/kg IV over 10 minutes</span></li>
<li><span style="color: #e69138;">IV Midazolam infusion: 0.1 – 1.0 mg/kg/hr, titrate to effect </span></li>
<li><span style="color: #e69138;">Can consider IV Levetiracetam (off-label use for Status Epilepticus)<span style="white-space: pre;"> </span></span></li>
</ul>
<li><span style="color: #e69138;">Third Line: intubation + mechanical ventilation + cEEG monitoring if available</span></li>
<ul>
<li><span style="color: #e69138;">IV Barbiturates: Phenobarbitone, Thiopentone</span></li>
<li><span style="color: #e69138;">IV Propofol: 2-3mg/kg IV then < 4mg/kg/hr</span></li>
<li><span style="color: #e69138;">IV Clonzepam </span></li>
</ul>
<li><span style="color: #e69138;">Fourth line: intubation + mechanical ventilation + cEEG monitoring if available</span></li>
<ul>
<li><span style="color: #e69138;">IV Ketamine</span></li>
<li><span style="color: #e69138;">Volatile Anaesthetic Agent</span></li>
</ul>
</ul>
<b><span style="color: #e69138;"><br /></span></b>
<b><span style="color: #e69138;">Identify and treat underlying cause</span></b><br />
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<span style="color: #e69138;"><b>Differential diagnosis of conditions that mimic seizures</b></span></div>
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</div>
<ul style="text-align: left;">
<li><span style="color: #e69138;">Eclampsia</span></li>
<li><span style="color: #e69138;">Nonepileptic seizures/ pseudoseizures</span></li>
<li><span style="color: #e69138;">Syncope</span></li>
<li><span style="color: #e69138;">Acute dystonic reactions</span></li>
<li><span style="color: #e69138;">Rigors</span></li>
<li><span style="color: #e69138;">Cardiac disorders (e.g. Dysrhythmias, Long QT syndrome, HOCM)</span></li>
</ul>
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<b style="mso-bidi-font-weight: normal;"><span style="color: #222a35; mso-themecolor: text2; mso-themeshade: 128;">History</span><o:p></o:p></b></h2>
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<span style="color: #0b5394;"><b>Signs/symptoms</b></span><br />
<ul style="text-align: left;">
<li><span style="color: #0b5394;">Seizure activity</span></li>
<li><span style="color: #0b5394;">Time of onset and offset (i.e. duration)</span></li>
<li><span style="color: #0b5394;">Warning signs</span></li>
<li><span style="color: #0b5394;">Parts of body involved in motor activity, and sequence of involvement</span></li>
<li><span style="color: #0b5394;">New vs recurrent</span></li>
<li><span style="color: #0b5394;">Fever</span></li>
<li><span style="color: #0b5394;">Pregnant / Post-partum (think Eclampsia)</span></li>
<li><span style="color: #0b5394;">Other clues regarding precipitants or factors which would lower seizure threshold</span></li>
</ul>
<b style="color: #0b5394;">Allergies</b><br />
<span style="color: #0b5394;"><b>Meds</b> </span><br />
<ul style="text-align: left;">
<li><span style="color: #0b5394;">Antiepileptics (? Compliance)</span></li>
<li><span style="color: #0b5394;">Antipsychotics, antidepressants, isoniazid</span></li>
<li><span style="color: #0b5394;">Recreational drugs, drug withdrawal</span></li>
<li><span style="color: #0b5394;">Insulin therapy</span></li>
</ul>
<b style="color: #0b5394;">PMHx</b><span style="color: #0b5394;">:</span><br />
<ul style="text-align: left;">
<li><span style="color: #0b5394;">Pre-existing hx of epilepsy, family hx, Renal Failure, Endocrinopathies</span></li>
<li><span style="color: #0b5394;">Alcohol +/- drug abuse</span></li>
</ul>
<b style="color: #0b5394;">Last oral intake</b><br />
<ul style="text-align: left;">
<li><span style="color: #0b5394;">Poison ingestion</span></li>
</ul>
<span style="color: #0b5394;"><b>Events</b></span><br />
<ul style="text-align: left;">
<li><span style="color: #0b5394;">As per above, looking for factors that may guide the cause for the seizure.</span></li>
</ul>
<div>
<span style="color: #0b5394;"><br /></span></div>
<div>
<span style="color: #cc0000;"><b>Red Flags</b></span></div>
<div>
<ul style="text-align: left;">
<li><span style="color: red;">Persistent GCS < 14</span></li>
<li><span style="color: red;">Hx of Status Epilepticus</span></li>
<li><span style="color: red;">Hx of Malignancy</span></li>
<li><span style="color: red;">Alcohol Withdrawal</span></li>
<li><span style="color: red;">Pregnancy / Post-partum</span></li>
</ul>
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<b style="mso-bidi-font-weight: normal;"><span style="color: #ff33ff;">Investigations</span></b><b style="mso-bidi-font-weight: normal;"><span style="color: #5f0272;"><o:p></o:p></span></b></h2>
</td>
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</tbody></table>
<ul style="text-align: left;">
<li><span style="color: purple;">VBG – Glucose + Basic Electrolytes + Lactate</span></li>
<li><span style="color: purple;">Urine Dipstick (and don't forget BhCG in females) + Formal M/C/S if indicated</span></li>
<li><span style="color: purple;">FBC + Chem20 (U&E + LFTs + Ck + CMP)</span></li>
<li><span style="color: purple;">Anticonvulsant Levels</span></li>
<li><span style="color: purple;">12-lead ECG (if considering toxins)</span></li>
</ul>
<span style="color: purple;">In Rural Hospitals (with Theatre capabilities), B</span><span style="color: purple;">ispectral index (BIS) monitoring may also provide some information to guide clinical management (when formal EEG monitoring is not available).</span></div>
<div dir="ltr" style="text-align: left;" trbidi="on">
<span style="color: purple;"><br /></span><span style="color: purple;">Also consider in select circumstances and as availability dictates;</span><br />
<ul style="text-align: left;">
<li><span style="color: purple;">CT Head</span></li>
<li><span style="color: purple;">Lumbar Puncture (concern re: CNS infection</span></li>
<li><span style="color: purple;">Blood/Urine Cultures</span></li>
<li><span style="color: purple;">Toxicology Screens</span></li>
<li><span style="color: purple;">EEG</span></li>
</ul>
<br />
<br />
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<td style="background: #92D050; height: 21.3pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 450.8pt;" valign="top" width="601"><h2 style="line-height: normal; mso-outline-level: 2;">
<b style="mso-bidi-font-weight: normal;"><span style="color: #009242;">Management<o:p></o:p></span></b></h2>
</td>
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<span style="color: #6aa84f;">This is one management approach to Afebrile Seizures given medication availability in Rural Hospitals. Please check your local protocols regarding specific medications. Maintenance of the ABCs is important, however it is useful to keep in mind that prioritizing the abortion of the seizure will often also optimise ABCs.</span><br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://1.bp.blogspot.com/-x32yiy5OKoY/WyDU1Zy6l_I/AAAAAAAADPY/4JtF5HBWf5MomJF_6z9JlVwzU6b31--rgCLcBGAs/s1600/Seizure%2BManagement.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="802" data-original-width="600" src="https://1.bp.blogspot.com/-x32yiy5OKoY/WyDU1Zy6l_I/AAAAAAAADPY/4JtF5HBWf5MomJF_6z9JlVwzU6b31--rgCLcBGAs/s1600/Seizure%2BManagement.png" /></a></div>
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<h4 style="clear: both; text-align: left;">
<span style="color: #6aa84f; font-weight: normal;">Anti-Epileptic Drugs</span></h4>
<div>
<span style="color: #6aa84f;">For individuals already on an Anti-Epileptic Drug/s (AED) often reloading their regular AED is an appropriate strategy for ongoing prophylaxis.</span></div>
<div>
<span style="color: #6aa84f;"><br /></span></div>
<h4 style="clear: both; text-align: left;">
<span style="color: #6aa84f; font-weight: normal;">Supportive Cares</span></h4>
<div class="separator" style="clear: both; text-align: left;">
</div>
<ul style="text-align: left;">
<li><span style="color: #6aa84f;"><b>Fluid therapy and feeding</b>: targeted fluid therapy to correct; hypoglycaemia, other metabolic and electrolyte derangements (e.g. hyper/hyponatraemia), hypovolaemia, </span><span style="color: #6aa84f;">rhabdomyolysis</span></li>
<li><b style="color: #6aa84f;">Anti-emetics</b><span style="color: #6aa84f;">: coughing and straining increases ICP, reduce chance of vomitus and potential airway hazards</span></li>
<li><span style="color: #6aa84f;"><b>Antibiotics / Antivirals</b>: in suspected bacterial / viral infections.</span></li>
<li><span style="color: #6aa84f;"><b>Sedation and analgesia:</b> Sedation to aid in terminating seizure.</span></li>
<li><span style="color: #6aa84f;"><b>Thromboprophylaxis</b>: routine indications</span></li>
<li><span style="color: #6aa84f;"><b>Head:</b> lateral / recovery position. head<b> </b>up position<b> </b>(30 degrees) in head injury or to reduce ICP</span></li>
<li><span style="color: #6aa84f;"><b>Ulcer prophylaxis: </b>typically not required.</span></li>
<li><span style="color: #6aa84f;"><b>Glucose control:</b> aim for normoglycaemia</span></li>
<li><span style="color: #6aa84f;"><b>Skin/eye care</b></span></li>
<li><span style="color: #6aa84f;"><b>Indwelling catheter</b>: to decrease intra-abdominal pressure and monitor urine output</span></li>
<li><span style="color: #6aa84f;"><b>Nasogastric tube</b>: orogastric is the preferred option in head trauma patients. Should be performed after intubation.</span></li>
<li><span style="color: #6aa84f;"><b>Bowel cares</b></span></li>
<li><span style="color: #6aa84f;"><b>Environment</b>: Maintain Normothermia (Temp 36-37; give antipyretics if Temp >38C) to prevent a rise in cerebral metabolic rate.</span></li>
</ul>
<br />
<h4 style="text-align: left;">
<span style="color: #6aa84f; font-weight: normal;">Rapid Sequence Termination (RST) of status epilepticus</span></h4>
<span style="color: #6aa84f;">Dr Josh Farkas from <a href="http://pulmcrit.org/">Pulmcrit.org</a> has developed his own algorithmic approach to treatment of Status Epilepticus with some further discussion around the role of intubation. See the <a href="https://emcrit.org/pulmcrit/status-epilepticus-2/"><i>Resuscitationist’s guide to status epilepticus</i></a> on Emcrit.org for more details.</span><br />
<br />
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<img border="0" data-original-height="542" data-original-width="750" height="433" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiDiE23rHGkKvtM8TpTWqURH4e8cJ8hWzG2ex7bv0yAU49MMmtcTCsxWT74xwNQp1onzz1-Rhtj_M99wt_EyE4NiQ8LPgBVoWiz71GVraaUIPNVivDAI2aPuo3-rHbFFgYopkDKJys_nQve/s640/Pulmcrit-StatusEpiAlgo.png" width="600" /><span id="goog_1182827190"></span><a href="https://emcrit.org/pulmcrit/status-epilepticus-2/"></a><span id="goog_1182827191"></span></div>
<br />
<br />
<h4 style="clear: both; text-align: left;">
<span style="color: #38761d;">Febrile Seizures </span></h4>
<div class="separator" style="clear: both; text-align: left;">
<span style="color: #38761d;">Febrile Seizures or convulsions typically occur between the ages of 6 months and 6 years. Most of these seizures resolve spontaneously and do not require anti-convulsant agents.</span></div>
<div class="separator" style="clear: both; text-align: left;">
<span style="color: #38761d;"><br /></span></div>
<div class="separator" style="clear: both; text-align: left;">
<span style="color: #38761d;">For more information on Febrile Seizures see the following <i><a href="https://www.rch.org.au/clinicalguide/guideline_index/Febrile_convulsion/">Royal Children's Hospital Guideline</a></i>.</span></div>
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<span style="color: #38761d;"><br /></span></div>
<h4 style="clear: both; text-align: left;">
<span style="color: #6aa84f;">Post-Seizure</span></h4>
<div class="separator" style="clear: both; text-align: left;">
<span style="color: #6aa84f;">Some key considerations post-seizure for the Rural Health Practitioner include;</span></div>
<div class="separator" style="clear: both; text-align: left;">
</div>
<ul style="text-align: left;">
<li><span style="color: #6aa84f;">Disposition; transfer to another facility / ward / HDU</span></li>
<li><span style="color: #6aa84f;">Specialist input: Neurologist +/- other critical care specialties as indicated</span></li>
<li><span style="color: #6aa84f;">Driving: Patients should be advised that they are not to drive for at least 6 months and after specialist clearance. Check your local regulations regarding time-frames and reporting.</span></li>
</ul>
<br />
<h3 style="clear: both; text-align: left;">
<span style="color: #444444;">
References / Further Resources</span></h3>
<div>
<span style="color: #444444;"></span><br />
<ul style="text-align: left;"><span style="color: #444444;">
<li><b>The Management of Epilepsy in Children and Adults (2018)</b></li>
<ul>
<li><a href="https://www.mja.com.au/system/files/issues/208_05/10.5694mja17.00951.pdf">https://www.mja.com.au/system/files/issues/208_05/10.5694mja17.00951.pdf</a></li>
</ul>
<li><b>Royal Children’s Hospital</b></li>
<ul>
<li>Afebrile Seizures <a href="https://www.rch.org.au/clinicalguide/guideline_index/Afebrile_Seizures/">https://www.rch.org.au/clinicalguide/guideline_index/Afebrile_Seizures/</a></li>
<li>Active Seizures Flowchart <a href="https://www.rch.org.au/clinicalguide/guideline_index/Management_flowchart_for_active_seizures/">https://www.rch.org.au/clinicalguide/guideline_index/Management_flowchart_for_active_seizures/</a></li>
<li>Febrile Seizures / Convulsion <a href="https://www.rch.org.au/clinicalguide/guideline_index/Febrile_convulsion">https://www.rch.org.au/clinicalguide/guideline_index/Febrile_convulsion</a></li>
</ul>
<li><b>LifeintheFastLane</b></li>
<ul>
<li>Status Epilepticus: <a href="https://lifeinthefastlane.com/ccc/status-epilepticus/">https://lifeinthefastlane.com/ccc/status-epilepticus/</a></li>
<li>Seizure DDx: <a href="https://lifeinthefastlane.com/resources/seizure-ddx/">https://lifeinthefastlane.com/resources/seizure-ddx/</a></li>
</ul>
<li><b>CoreEM: </b></li>
<ul>
<li>First Time Seizure: <a href="https://coreem.net/core/1st-time-seizure">https://coreem.net/core/1st-time-seizure</a></li>
</ul>
<li><b>PulmCrit- Resuscitationist’s guide to status epilepticus</b></li>
<ul>
<li><a href="https://emcrit.org/pulmcrit/status-epilepticus-2/">https://emcrit.org/pulmcrit/status-epilepticus-2/</a></li>
</ul>
<li><b>NeuroCriticalCare Guidelines 2012</b></li>
<ul>
<li><a href="http://neurocriticalcare.ucsd.edu/wp-content/uploads/2012/11/NCS-StatusEpilepticus-Guideline-2012.pdf">http://neurocriticalcare.ucsd.edu/wp-content/uploads/2012/11/NCS-StatusEpilepticus-Guideline-2012.pdf</a></li>
</ul>
<li><b>Does the Bispectral Index Monitor have a Role in Intensive Care?</b></li>
<ul>
<li><a href="http://journals.sagepub.com/doi/abs/10.1177/175114371201300410">http://journals.sagepub.com/doi/abs/10.1177/175114371201300410</a></li>
</ul>
</span></ul>
</div>
</div>
Aaron Sparshotthttp://www.blogger.com/profile/16868086818074290497noreply@blogger.com0tag:blogger.com,1999:blog-4281944981424326587.post-87023854685797649082018-07-04T10:22:00.001+10:002018-07-04T10:22:24.461+10:00The Ultimate Guide to Trauma - Part 3<div dir="ltr" style="text-align: left;" trbidi="on">
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<a href="http://1.bp.blogspot.com/-lPeNb9-d9PI/T4VaF1NM5UI/AAAAAAAABNA/rjcrsFI3rb0/s1600/TraumaGuide-egg.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="253" src="https://1.bp.blogspot.com/-lPeNb9-d9PI/T4VaF1NM5UI/AAAAAAAABNA/rjcrsFI3rb0/s400/TraumaGuide-egg.jpg" width="400" /></a></div>
<br />
<div style="text-align: left;">
The folks over at <a href="http://lifeinthefastlane.com/">LifeintheFastLane</a> have released a series of great posts on Trauma assessment and management. What I've provided here is a collated version of a selection of these posts, along with relevant resources from other sources, to create <i>The Ultimate Guide to Trauma for Junior Doctors and Medical Students</i>.</div>
<div style="text-align: left;">
<br /></div>
<div style="text-align: left;">
Most of the posts are done in a Q&A style so you can put your knowledge to test. In <a href="http://www.ivline.org/2012/04/ultimate-guide-to-trauma.html">Part One</a> we covered the basics (BLS & ALS, initial assessment & management), one step further (major haemorrhage, transfusions and intubation), considered
abdominal and genitourinary trauma, chest trauma and trauma in
pregnancy. In <a href="http://www.ivline.org/2012/04/ultimate-guide-to-trauma-part-2.html">Part Two</a>, we covered central nervous trauma, eye trauma and general radiology. In Part Three we cover Musculoskeletal / Orthopaedic Injuries, particularly looking at life and limb threatening injuries.<br />
<br />
<h3 style="text-align: left;">
General Principles</h3>
<b>Primary Survey</b><br />
Use the ATLS ABCDE approach to help guide your assessment, identifying and correct issues as found. Bear in mind that life-threatening haemorrhage (though traditionally thought as part of Circulation) is considered a simultaneously priority. People will and have died from exsanguination from pelvic and long bone fractures, whilst people are still focusing on the Airway.<br />
<br />
Another approach adapted from the Military is <i>MARCH </i>which may be applicable at times.<br />
<br />
<ul style="text-align: left;">
<li>M assive Haemorrhage (4 D's)</li>
<ul>
<li>Detect: find the source of the bleeding.</li>
<li>Direct pressure: hold pressure on the source of the bleeding until the clot forms.</li>
<li>Devices: if necessary, use equipment such as tourniquets, hemostatic gauze and pressure bandages to supplement direct pressure.</li>
<li>Don’t dilute: use the concept of hypotensive resuscitation to avoid thinning the blood or pumping established clots. Saline does not carry oxygen.</li>
</ul>
<li>A irway Control</li>
<li>R espiratory Support</li>
<li>C irculation</li>
<li>H ead Trauma / Hypothermia</li>
</ul>
<br />
Adequate imaging is a must - Xray first. CT should be delayed until stabilisation has been accomplished.<br />
Fracture Immobilisation & Stabilsation.<br />
<br />
<b>Secondary Survey</b><br />
Further assessment of core and limb musculoskeletal structure is often conducted during the secondary survey. The suggested approach below is adapted from the ATACC Manual.<br />
<br />
AMPLE Hx<br />
Look<br />
<ul style="text-align: left;">
<li>wounds, laceration, contusions</li>
<li>deformity</li>
<li>colour, perfusion </li>
</ul>
Feel<br />
<ul style="text-align: left;">
<li>assess neurovascular status (e.g. pulses)</li>
<li>tenderness</li>
<li>crepitis</li>
<li>temperature</li>
</ul>
Move<br />
<ul style="text-align: left;">
<li>joint stability</li>
<li>abnormal or limited movement</li>
</ul>
Assess for associated injuries<br />
<div>
Reduce fracture and/or dislocation</div>
<br />
<br />
<b>Life Threatening Injuries</b><br />
<ul style="text-align: left;">
<li>Pelvic Disruption with Haemorrhage</li>
<li>Major Arterial Haemorrhage</li>
<li>Crush Syndrome</li>
</ul>
<br />
<br />
<b>Limb Threatening Injuries</b><br />
<ul style="text-align: left;">
<li>Open Fractures / Joint Injuries</li>
<li>Long Bone Fractures</li>
<li>Vascular Injuries</li>
<li>Compartment Syndrome</li>
</ul>
<br />
<b>Surgical Intervention</b><br />
As per <a href="https://www.orthobullets.com/trauma/1005/evaluation-resuscitation-and-dco?expandLeftMenu=true">OrthoBullets.com</a> there are select number of conditions that may require prompt surgical intervention.<br />
<blockquote class="tr_bq">
<ul style="text-align: left;">
<li>unstable pelvic fracture</li>
<li>compartment syndrome</li>
<li>fractures with vascular injuries</li>
<li>unreduced dislocations</li>
<li>traumatic amputations</li>
<li>unstable spine fractures</li>
<li>cauda equina syndrome</li>
<li>open fractures</li>
</ul>
</blockquote>
<br />
<h4 style="text-align: left;">
<a href="https://lifeinthefastlane.com/bone-and-joint-bamboozler-002/">Compartment Syndrome</a></h4>
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<a href="https://lifeinthefastlane.com/bone-and-joint-bamboozler-002/" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="100" data-original-width="100" src="https://1.bp.blogspot.com/-FrYOz_zWYN0/Wzt5kT0RT6I/AAAAAAAADR4/JXAOyTuGNT8Du4oKxHx7d0_LrUwrj6LgQCLcBGAs/s1600/Compartment%2BSyndrome%2B-%2BFasciotomy.gif" /></a></div>
Compartment syndrome is a limb-threatening condition, that causes compression of vessels, muscles and nerves within a fascial compartment. The three key symptoms are pain out of proportion to injury, persistent deep ache or burning pain and parathesia in a peripheral nerve distribution (typical onset 30 minutes to 2hrs).<br />
<br />
Management includes relieving external pressure (e.g. <i>remove constrictive dressings or casts</i>), analgesia, supplementary oxygen, followed by internal pressure relief (e.g. <i>surgical Fasciotomy</i>).<br />
<br />
<b>6 P's for Critical Limb Ischaemia</b><br />
Pain, Paresthesia, Paresis, Pallor, Pulselessness, Poikilothermia<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://www.aliem.com/2018/01/infographic-compartment-syndrome/"><img border="0" data-original-height="420" data-original-width="560" height="300" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEioiAvmwdGLerCw6m0P37-9_u9ir3ReKXPlRSGhJxn8grfWO5ubaxPt5uz7t0qRIDNx0GjT14q7fVnep0NmOwMOxAGZxxF1YPuXSSlIrp3R5WHJd3OiJlgokM3dp7s7LykhABd2dfopRpWH/s400/Compartment+Syndrome.gif" width="400" /></a></div>
<div style="text-align: center;">
<span style="font-size: xx-small;">Compartment Syndrome by Katelyn Hanson, DO. <a href="https://www.aliem.com/2018/01/infographic-compartment-syndrome/">Fullsize on ALEIM</a>. </span></div>
<div style="text-align: center;">
<span style="font-size: xx-small;"><br /></span></div>
<h3 style="text-align: left;">
<a href="https://www.rch.org.au/clinicalguide/fractures/#">Paediatric Fractures</a></h3>
The <a href="https://www.rch.org.au/clinicalguide/fractures/#"><i>Royal Children's Hospital Clinical Guidelines</i></a> provide a nice clear overview of Fracture Management in children.<br />
<br />
<ul style="background-color: white; box-sizing: border-box; font-family: arial, helvetica, sans-serif; font-size: 13px; margin-bottom: 9px; margin-top: 0px;">
<li style="box-sizing: border-box;"><a href="https://www.rch.org.au/clinicalguide/guideline_index/fractures/Clavicle_fractures_Emergency_Department/" id="fgClavicle" style="background: transparent; box-sizing: border-box;"><span style="color: #073763;">Clavicle</span></a></li>
<li style="box-sizing: border-box;"><a href="https://www.rch.org.au/clinicalguide/guideline_index/fractures/Proximal_humeral_fractures_Emergency_Department/" id="fgHumerus" style="background: transparent; box-sizing: border-box;"><span style="color: #073763;">Proximal humerus</span></a></li>
<li style="box-sizing: border-box;"><a href="https://www.rch.org.au/clinicalguide/guideline_index/fractures/Humeral_shaft_fractures_Emergency_Department/" id="fgDiaphysis" style="background: transparent; box-sizing: border-box;"><span style="color: #073763;">Humeral shaft (diaphysis)</span></a></li>
<li style="box-sizing: border-box;"><a href="https://www.rch.org.au/clinicalguide/guideline_index/Elbow_fractures/" id="fgElbow" style="background: transparent; box-sizing: border-box;"><span style="color: #073763;">Elbow</span></a><ul style="box-sizing: border-box; margin-bottom: 0px; margin-top: 0px;">
<li style="box-sizing: border-box;"><a href="https://www.rch.org.au/clinicalguide/guideline_index/fractures/Supracondylar_fracture_of_the_humerus_Emergency_Department/" id="fgSupracondylar" style="background: transparent; box-sizing: border-box;"><span style="color: #3d85c6;">Supracondylar</span></a></li>
<li style="box-sizing: border-box;"><a href="https://www.rch.org.au/clinicalguide/guideline_index/fractures/Lateral_condyle_fracture_of_the_humerus_Emergency_Department_setting/" id="fgLateralCondyle" style="background: transparent; box-sizing: border-box;"><span style="color: #3d85c6;">Lateral condyle</span></a></li>
<li style="box-sizing: border-box;"><a href="https://www.rch.org.au/clinicalguide/guideline_index/fractures/Medial_epicondyle_emerg/" id="fgMedialEpicondyle" style="background: transparent; box-sizing: border-box;"><span style="color: #3d85c6;">Medial epicondyle</span></a></li>
<li style="box-sizing: border-box;"><a href="https://www.rch.org.au/clinicalguide/guideline_index/fractures/Monteggia_fracturedislocations_Emergency_Department_setting/" id="fgMonteggia" style="background: transparent; box-sizing: border-box;"><span style="color: #3d85c6;">Monteggia fracture-dislocation</span></a></li>
<li style="box-sizing: border-box;"><a href="https://www.rch.org.au/clinicalguide/guideline_index/fractures/Olecranon_fracture_Emergency_Department_setting/" id="fgOlecranon" style="background: transparent; box-sizing: border-box;"><span style="color: #3d85c6;">Olecranon</span></a></li>
<li style="box-sizing: border-box;"><a href="https://www.rch.org.au/clinicalguide/guideline_index/fractures/Radial_neck_fractures_Emergency_Department_setting/" id="fgRadialNeck" style="background: transparent; box-sizing: border-box;"><span style="color: #3d85c6;">Radial neck</span></a></li>
</ul>
</li>
<li style="box-sizing: border-box;"><a href="https://www.rch.org.au/clinicalguide/guideline_index/forearm_fractures/" id="fgForearm" style="background: transparent; box-sizing: border-box;"><span style="color: #073763;">Forearm</span></a><ul style="box-sizing: border-box; margin-bottom: 0px; margin-top: 0px;">
<li style="box-sizing: border-box;"><a href="https://www.rch.org.au/clinicalguide/guideline_index/fractures/Radialulna_shaft_diaphysis_fractures_Emergency_Department/" id="fgRadiusUlnaShaft" style="background: transparent; box-sizing: border-box;"><span style="color: #3d85c6;">Radius and ulna shaft (diaphysis)</span></a></li>
<li style="box-sizing: border-box;"><a href="https://www.rch.org.au/clinicalguide/guideline_index/fractures/Monteggia_fracturedislocations_Emergency_Department_setting/" id="fgMonteggiaFractureDislocation" style="background: transparent; box-sizing: border-box;"><span style="color: #3d85c6;">Monteggia fracture-dislocation</span></a></li>
<li style="box-sizing: border-box;"><a href="https://www.rch.org.au/clinicalguide/guideline_index/fractures/Galeazzi_fracturedislocations_Emergency_Department_setting/" id="fgGaleazziFractureDislocation" style="background: transparent; box-sizing: border-box;"><span style="color: #3d85c6;">Galeazzi fracture-dislocation</span></a></li>
</ul>
</li>
<li style="box-sizing: border-box;"><a href="https://www.rch.org.au/clinicalguide/guideline_index/wrist_fractures/" id="fgWrist" style="background: transparent; box-sizing: border-box;"><span style="color: #073763;">Wrist – distal radius and ulna</span></a><ul style="box-sizing: border-box; margin-bottom: 0px; margin-top: 0px;">
<li style="box-sizing: border-box;"><a href="https://www.rch.org.au/clinicalguide/guideline_index/fractures/Distal_radius_and_or_ulna_metaphyseal_fractures_Emergency_Department_setting/" id="fgMetaphyseal" style="background: transparent; box-sizing: border-box;"><span style="color: #3d85c6;">Metaphyseal</span></a></li>
<li style="box-sizing: border-box;"><a href="https://www.rch.org.au/clinicalguide/guideline_index/fractures/Distal_radial_physeal_fractures_Emergency_Department_setting/" id="fgPhyseal" style="background: transparent; box-sizing: border-box;"><span style="color: #3d85c6;">Physeal (growth plate)</span></a></li>
</ul>
</li>
<li style="box-sizing: border-box;"><a href="https://www.rch.org.au/clinicalguide/guideline_index/hip-and-proximal-femur-fractures/" id="fgHipMain" style="background: transparent; box-sizing: border-box;"><span style="color: #073763;">Hip and proximal femur</span></a><ul style="box-sizing: border-box; margin-bottom: 0px; margin-top: 0px;">
<li style="box-sizing: border-box;"><a href="https://www.rch.org.au/clinicalguide/guideline_index/fractures/sufe_emergency/" id="fgSUFE" style="background: transparent; box-sizing: border-box;"><span style="color: #3d85c6;">SUFE</span></a></li>
<li style="box-sizing: border-box;"><a href="https://www.rch.org.au/clinicalguide/guideline_index/fractures/hip_dislocation_emergency/" id="fgHipDislocation" style="background: transparent; box-sizing: border-box;"><span style="color: #3d85c6;">Hip dislocation</span></a></li>
<li style="box-sizing: border-box;"><a href="https://www.rch.org.au/clinicalguide/guideline_index/fractures/neck_of_femur_emergency/" id="fgNeckOfFemur" style="background: transparent; box-sizing: border-box;"><span style="color: #3d85c6;">Neck of femur</span></a></li>
</ul>
</li>
<li style="box-sizing: border-box;"><a href="https://www.rch.org.au/clinicalguide/guideline_index/fractures/femoral_shaft_emergency/" id="fgFemoralShaft" style="background: transparent; box-sizing: border-box;"><span style="color: #073763;">Femoral shaft (diaphysis)</span></a></li>
<li style="box-sizing: border-box;"><a href="https://www.rch.org.au/clinicalguide/guideline_index/fractures/tibial_shaft_emergency/" id="fgTibialShaft" style="background: transparent; box-sizing: border-box;"><span style="color: #073763;">Tibial shaft (diaphysis)</span></a></li>
<li style="box-sizing: border-box;"><span style="color: #073763;"><a href="https://www.rch.org.au/clinicalguide/guideline_index/fractures/ankle_emergency/" id="fgAnkle" style="background: transparent; box-sizing: border-box;">Ankle - distal tibial and fibula physe</a>al</span></li>
</ul>
<span style="color: #3d5567; font-family: "arial" , "helvetica" , sans-serif;"><span style="font-size: 13px;"><br /></span></span>
<br />
<h3 style="text-align: left;">
Hip/Pelvis</h3>
<div>
Pelvic trauma is important as the mortality and morbidity associated with these injuries is high.<br />
Injuries mechanisms include potential for massive haemorrhage, neurovascular compromise and associated soft tissue and abdominal injuries.<br />
<br />
<b>Hip Dislocation</b></div>
<div>
Read more on OrthoBullets: <a href="http://www.orthobullets.com/trauma/1035/hip-dislocation">www.orthobullets.com/trauma/1035/hip-dislocation</a></div>
<div>
<br /></div>
<div>
<b>Acetabular Fracture</b><br />
Read more on OrthoBullets: <a href="http://www.orthobullets.com/trauma/1034/acetabular-fractures">www.orthobullets.com/trauma/1034/acetabular-fractures</a></div>
<div class="separator" style="clear: both; text-align: left;">
<a href="https://3.bp.blogspot.com/-KAbzb-aqfiA/WzteXvIjdjI/AAAAAAAADRk/MpjZD11x3e4tP-Nn-j_3evOrvJhkWy_JwCLcBGAs/s1600/Acetabulum%2Bfractures%2Bclassification%2B-s.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="230" data-original-width="600" height="153" src="https://3.bp.blogspot.com/-KAbzb-aqfiA/WzteXvIjdjI/AAAAAAAADRk/MpjZD11x3e4tP-Nn-j_3evOrvJhkWy_JwCLcBGAs/s400/Acetabulum%2Bfractures%2Bclassification%2B-s.jpg" width="400" /></a></div>
<div>
<br /></div>
<div>
<br /></div>
<a href="https://lifeinthefastlane.com/trauma-tribulation-027/"><b>Pelvic Fractures I</b> <b>- Initial Workup and Classification</b></a><br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjrjarAmzGwhcXM4f1eOqnR-HFFFs0RBT-pK3YK3CcC7xxnEuaFNlUEwUlPSIVHWbilaFlQWkZ4Cy1aBG9hzuI92myg20LO1o1IItG4DmJItYtdNb8VyxM8vgQcB4Gply1jHh4Z45O5G6vp/s1600/Pelvic+Fracture+1.gif" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="100" data-original-width="100" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjrjarAmzGwhcXM4f1eOqnR-HFFFs0RBT-pK3YK3CcC7xxnEuaFNlUEwUlPSIVHWbilaFlQWkZ4Cy1aBG9hzuI92myg20LO1o1IItG4DmJItYtdNb8VyxM8vgQcB4Gply1jHh4Z45O5G6vp/s1600/Pelvic+Fracture+1.gif" /></a></div>
A fractured Pelvic Ring fracture can be difficult to diagnose in Trauma. Assessment includes the usual look, feel and a very cautious approach to the move component. In the literature there is mention of avoiding distracting the pelvis all together given the availability of plain radiography. The rectum (PR Exam), perineum and genetilia, lower limbs and abdomen also need to be examined in the initial workup for any associated injuries.<br />
<br />
Two common classifications systems are used often in conjunction in Pelvic Trauma.<br />
<br />
Tile: <i>is about stability</i><br />
<ul style="text-align: left;">
<li>a stable</li>
<li>b partial unstable (e.g. b1 open book #)</li>
<li>c unstable</li>
</ul>
<br />
<div class="separator" style="clear: both; text-align: left;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgneqdPquhTNNkKF3d-Zd5tHkzH2V-rFJkF6qjaBhKzkQ88eubdUioySzJj0u-fA-qSWxfnlN9JPpnFPJdq-oV79r6TWciF7ONhnfEcNUxNsF-t7dps89UvDcBFunUEqn6c2buTTQAHnbCO/s1600/565px-Classification_by_Tile.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="600" data-original-width="565" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgneqdPquhTNNkKF3d-Zd5tHkzH2V-rFJkF6qjaBhKzkQ88eubdUioySzJj0u-fA-qSWxfnlN9JPpnFPJdq-oV79r6TWciF7ONhnfEcNUxNsF-t7dps89UvDcBFunUEqn6c2buTTQAHnbCO/s200/565px-Classification_by_Tile.png" width="188" /></a></div>
<div class="separator" style="clear: both; text-align: left;">
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Young-Burgess:<i> is about mechanism</i><br />
<br />
<div class="separator" style="clear: both; text-align: left;">
<a href="https://3.bp.blogspot.com/-DJ6TVU_Cw-8/WzsPkUWFobI/AAAAAAAADRY/u0vOp0Mfz6IHHt-Cy3UDeIFinDqg1rlNwCLcBGAs/s1600/600px-Classification_by_Young_and_Burgess.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="539" data-original-width="600" height="179" src="https://3.bp.blogspot.com/-DJ6TVU_Cw-8/WzsPkUWFobI/AAAAAAAADRY/u0vOp0Mfz6IHHt-Cy3UDeIFinDqg1rlNwCLcBGAs/s200/600px-Classification_by_Young_and_Burgess.png" width="200" /></a></div>
<div class="separator" style="clear: both; text-align: left;">
<br /></div>
<div class="separator" style="clear: both; text-align: left;">
Be aware FAST can be negative, retroperitoneal bleed.</div>
<div class="separator" style="clear: both; text-align: left;">
<br /></div>
Read more on Phsyiopedia: <a href="http://www.physio-pedia.com/Pelvic_Fractures">www.physio-pedia.com/Pelvic_Fractures</a><br />
Read more on Radiopedia: <a href="http://radiopaedia.org/articles/pelvic-fractures">radiopaedia.org/articles/pelvic-fractures</a><br />
Read more on OrthoBullets: <a href="http://www.orthobullets.com/trauma/1030/pelvic-ring-fractures">www.orthobullets.com/trauma/1030/pelvic-ring-fractures</a><br />
<br />
<a href="https://lifeinthefastlane.com/trauma-tribulation-028/"><b>Pelvic Fractures II</b> <b>- Management and Complications</b></a><br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh2zFj57qeR8lMjxOrNmLN6no13sF2DxjWmj_-KGSX5u-imS9PqEj3lgRuRk5mReqsqU3fj2vHsvrjjZwITZatOUSPIGhWI5hW1dM-Hytc42AXYPr7N-k22QUG7vD3eYqNCMw5NxoboW48_/s1600/Pelvic+Fracture+2.gif" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="100" data-original-width="100" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh2zFj57qeR8lMjxOrNmLN6no13sF2DxjWmj_-KGSX5u-imS9PqEj3lgRuRk5mReqsqU3fj2vHsvrjjZwITZatOUSPIGhWI5hW1dM-Hytc42AXYPr7N-k22QUG7vD3eYqNCMw5NxoboW48_/s1600/Pelvic+Fracture+2.gif" /></a></div>
Management of Pelvic fractures is about maintenance of ABCDE, early stabilisation of the fracture, and minimisation of complications. The patient's haemodynamic stability will also guide management efforts. <a href="https://www.aliem.com/2017/07/management-major-pelvic-trauma/">ALIEM</a> provides a succint overview of management of <a href="https://www.aliem.com/2017/07/management-major-pelvic-trauma/">Major Pelvic Trauma</a> including a section on the use of REBOA.<br />
<br />
<br />
Compression and Pelvic Binders<br />
<br />
<ul style="text-align: left;">
<li>EMRAP Pelvic Binders: <a href="https://www.youtube.com/watch?v=8dCntKAExBk">Youtube</a></li>
<li>Quick Pelvic Wrap (sheet) Demo: <a href="https://www.youtube.com/watch?v=Omg79Ced6s0">Youtube</a></li>
<li>Queensland Ambulance Service: <a href="https://www.ambulance.qld.gov.au/docs/clinical/cpp/CPP_Pelvic%20circumferential%20compression%20device.pdf">Pelvic Compression Device</a></li>
<li>Royal Melbourne Hospital: <a href="https://www.thermh.org.au/sites/default/files/media/documents/clinical/TRM06.02.pdf">Pelvic Guideline </a></li>
</ul>
<br />
<br />
Complications<br />
<ul style="text-align: left;">
<li>Associated injuries</li>
<ul>
<li>Urologic</li>
<li>Neurologic</li>
<li>Gynaecologic</li>
<li>Gastrointestinal</li>
</ul>
<li>Hypovolaemia / Shock</li>
<li>Infection in open fractures</li>
</ul>
<b>RCH: <a href="https://www.rch.org.au/clinicalguide/guideline_index/Trauma_%E2%80%93_Early_management_of_pelvic_injuries_in_children/">Early management of pelvic injuries in children</a></b><br />
<br />
<h3 style="text-align: left;">
Upper Limb</h3>
<b>Brachial Plexus</b><br />
Read more on OrthoBullets: <a href="https://www.orthobullets.com/trauma/1008/brachial-plexus-injuries">B</a><a href="https://www.orthobullets.com/trauma/1008/brachial-plexus-injuries">rachial Plexus Injuries</a><br />
<br />
<b>Shoulder / Humerus</b><br />
LITFL: <a href="https://lifeinthefastlane.com/a-funny-fracture/">https://lifeinthefastlane.com/a-funny-fracture/</a><br />
Flashcards (Blunt dissection)<br />
<ul style="text-align: left;">
<li><a href="https://www.evernote.com/shard/s240/sh/628a40db-6907-4bf8-afb2-d011a108dc49/db79eb37d9e85f3b247221206b981b20" style="background-color: white; box-sizing: border-box; color: #5bb1f9; font-family: Arial, Helvetica, sans-serif; font-size: 13px; margin: 0px; padding: 0px; transition: all 0.1s ease-in-out;">Shoulder Dislocations</a></li>
<li><a href="https://www.evernote.com/shard/s240/sh/daa95293-20f1-4fa3-88d6-d4dc801fe4fe/4d1ba8635f45f9acc71ec00f48812cc7" style="background-color: white; box-sizing: border-box; color: #5bb1f9; font-family: Arial, Helvetica, sans-serif; font-size: 13px; margin: 0px; padding: 0px; transition: all 0.1s ease-in-out;">Shoulder Relocation Techniques</a></li>
</ul>
Read more on OrthoBullets:<br />
<ul style="text-align: left;">
<li><a href="https://www.orthobullets.com/trauma/1015/proximal-humerus-fractures?expandLeftMenu=true">Proximal Humerus FX</a></li>
<li><a href="https://www.orthobullets.com/trauma/1016/humeral-shaft-fractures?expandLeftMenu=true">Humeral Shaft FX</a></li>
<li><a href="https://www.orthobullets.com/trauma/1017/distal-humerus-fractures?expandLeftMenu=true">Distal Humerus FX</a></li>
</ul>
<br />
<b>Elbow</b><br />
Flashcards (Blunt dissection)<br />
<ul style="text-align: left;">
<li><a href="https://www.evernote.com/shard/s240/sh/4de5b7f5-a1d8-46c8-ac55-b02816c7eed2/08299b2e90fa0cf81e223c588108d2b6" style="background-color: white; box-sizing: border-box; color: #5bb1f9; font-family: Arial, Helvetica, sans-serif; font-size: 13px; margin: 0px; padding: 0px; transition: all 0.1s ease-in-out;">Elbow Xray</a></li>
<li><a href="https://www.evernote.com/shard/s240/sh/551418e6-8f6f-4d7e-8171-8aa69fa6110a/a2cc4f5fc7e3fe1d9c6180b19ff92165" style="background-color: white; box-sizing: border-box; color: #5bb1f9; font-family: Arial, Helvetica, sans-serif; font-size: 13px; margin: 0px; padding: 0px; transition: all 0.1s ease-in-out;">Elbow Dislocation</a></li>
</ul>
Read more on OrthoBullets:<br />
<ul style="text-align: left;">
<li><a href="https://www.orthobullets.com/trauma/1023/capitellum-fractures?expandLeftMenu=true">Capitellum FX</a></li>
<li><a href="https://www.orthobullets.com/trauma/1020/coronoid-fractures?expandLeftMenu=true">Coronoid FX</a></li>
<li><a href="https://www.orthobullets.com/trauma/1022/olecranon-fractures?expandLeftMenu=true">Olecranon FX</a></li>
<li><a href="https://www.orthobullets.com/trauma/1019/radial-head-fractures?expandLeftMenu=true">Radial Head FX</a></li>
<li><a href="https://www.orthobullets.com/trauma/1018/elbow-dislocation?expandLeftMenu=true">Elbow Dislocation</a></li>
<li><a href="https://www.orthobullets.com/trauma/1021/terrible-triad-injury-of-elbow?expandLeftMenu=true">Terrible Triad Injury of Elbow</a></li>
</ul>
<br />
<br />
<b>Forearm / Wrist</b><br />
LITFL: <a href="https://lifeinthefastlane.com/bone-and-joint-bamboozler-003/">https://lifeinthefastlane.com/bone-and-joint-bamboozler-003/</a><br />
Flashcards (Blunt dissection)<br />
<ul style="text-align: left;">
<li><a href="https://www.evernote.com/shard/s240/sh/8b347db9-8587-4a84-8c53-d59d16ddb7aa/d23e74126b7e898a642e55c6844ad259" style="background-color: white; box-sizing: border-box; color: #5bb1f9; font-family: Arial, Helvetica, sans-serif; font-size: 13px; margin: 0px; padding: 0px; transition: all 0.1s ease-in-out;">Distal Radial Fractures (Colles, Smith & Barton)</a></li>
<li><a href="https://www.evernote.com/shard/s240/sh/b931bc97-2a36-4296-8937-88219ffb43b6/9a5e51942c286e8f24c2fa890e49dcf5" style="background-color: white; box-sizing: border-box; color: #5bb1f9; font-family: Arial, Helvetica, sans-serif; font-size: 13px; margin: 0px; padding: 0px; transition: all 0.1s ease-in-out;">Forearm Fractures</a></li>
<li><a href="https://www.evernote.com/shard/s240/sh/297f4134-ba3a-4534-a9bd-aa6c09759034/9eeacd7834ad9a5643c67f7c7a1dbd54" style="background-color: white; box-sizing: border-box; color: #5bb1f9; font-family: Arial, Helvetica, sans-serif; font-size: 13px; margin: 0px; padding: 0px; transition: all 0.1s ease-in-out;">Scaphoid Fracture</a></li>
<li><a href="https://www.evernote.com/shard/s240/sh/2e6ff7cb-749d-491a-9fbb-8a3eb19eff3b/5909a3de4f446bd4b96a4902b5bb9fdb" style="background-color: white; box-sizing: border-box; color: #5bb1f9; font-family: Arial, Helvetica, sans-serif; font-size: 13px; margin: 0px; padding: 0px; transition: all 0.1s ease-in-out;">Scapholunate Dissociation</a></li>
<li><a href="https://www.evernote.com/shard/s240/sh/b3a037b7-363e-4d92-b86a-e451d1e75aa4/a4970c3c371f863b2cb166d6d6f8a719" style="background-color: white; box-sizing: border-box; color: #5bb1f9; font-family: Arial, Helvetica, sans-serif; font-size: 13px; margin: 0px; padding: 0px; transition: all 0.1s ease-in-out;">Lunate & Perilunate Dislocations</a></li>
</ul>
Read more on OrthoBullets:<br />
<ul style="text-align: left;">
<li><a href="https://www.orthobullets.com/trauma/1024/monteggia-fractures?expandLeftMenu=true">Monteggia FX</a></li>
<li><a href="https://www.orthobullets.com/trauma/1025/radius-and-ulnar-shaft-fractures?expandLeftMenu=true">Radius and Ulnar Shaft FX</a></li>
<li><a href="https://www.orthobullets.com/trauma/1027/distal-radius-fractures?expandLeftMenu=true">Distal Radius FX</a></li>
<li><a href="https://www.orthobullets.com/trauma/1028/distal-radial-ulnar-joint-druj-injuries?expandLeftMenu=true">Distal Radial Ulnar Joint (DRUJ) Injuries</a></li>
<li><a href="https://www.orthobullets.com/trauma/1029/galeazzi-fractures?expandLeftMenu=true">Galeazzi FX</a></li>
</ul>
<br />
<h3 style="text-align: left;">
Lower Limb</h3>
Flashcards (Blunt dissection)<br />
<ul style="text-align: left;">
<li><a href="https://www.evernote.com/shard/s240/sh/e49c26f3-074f-4881-94e5-955e5141c7db/e5a8e00992889dc54dddb8d0dcfd932b" style="background-color: white; box-sizing: border-box; color: #5bb1f9; font-family: Arial, Helvetica, sans-serif; font-size: 13px; margin: 0px; padding: 0px; transition: all 0.1s ease-in-out;">Ottawa Knee Rules</a></li>
<li><a href="https://www.evernote.com/shard/s240/sh/a8a66ce6-1ccf-4659-8e58-05e0a2f5fe52/dc5379c356eaa054fbca61aa7963283a" style="background-color: white; box-sizing: border-box; color: #5bb1f9; font-family: Arial, Helvetica, sans-serif; font-size: 13px; margin: 0px; padding: 0px; transition: all 0.1s ease-in-out;">Ottawa Ankle Rules</a></li>
<li><a href="https://www.evernote.com/shard/s240/sh/454dbc88-f36f-4a1b-9077-5cebb22b6f02/fc98f8496b552e8f4e148f6e624cc4af" style="background-color: white; box-sizing: border-box; color: #5bb1f9; font-family: Arial, Helvetica, sans-serif; font-size: 13px; margin: 0px; padding: 0px; transition: all 0.1s ease-in-out;">Lower Leg Compartments</a></li>
<li><a href="https://www.evernote.com/shard/s240/sh/54630a92-0e56-4f07-bc53-8c798051605e/4934af47b48169c91e46b69b9e93555f" style="background-color: white; box-sizing: border-box; color: #5bb1f9; font-family: Arial, Helvetica, sans-serif; font-size: 13px; margin: 0px; padding: 0px; transition: all 0.1s ease-in-out;">Lower Leg Fractures</a></li>
</ul>
<br />
<b>Femur</b><br />
ACI NSW Health: <a href="https://www.aci.health.nsw.gov.au/networks/eci/clinical/clinical-resources/clinical-tools/orthopaedic-and-musculoskeletal/femur-splints">How to put on a femur splint</a><br />
Read more on OrthoBullets:<br />
<ul style="text-align: left;">
<li><a href="https://www.orthobullets.com/trauma/1036/femoral-head-fractures?expandLeftMenu=true">Femoral Head FX</a></li>
<li><a href="https://www.orthobullets.com/trauma/1037/femoral-neck-fractures?expandLeftMenu=true">Femoral Neck FX</a></li>
<li><a href="https://www.orthobullets.com/trauma/1038/intertrochanteric-fractures?expandLeftMenu=true">Intertrochanteric FX</a></li>
<li><a href="https://www.orthobullets.com/trauma/1039/subtrochanteric-fractures?expandLeftMenu=true">Subtrochanteric FX</a></li>
<li><a href="https://www.orthobullets.com/trauma/1040/femoral-shaft-fractures?expandLeftMenu=true">Femoral Shaft FX</a></li>
<li><a href="https://www.orthobullets.com/trauma/1041/distal-femur-fractures?expandLeftMenu=true">Distal Femur FX</a></li>
</ul>
<br />
<b>Leg</b><br />
Read more on OrthoBullets:<br />
<ul style="text-align: left;">
<li><a href="https://www.orthobullets.com/trauma/1044/tibial-plateau-fractures?expandLeftMenu=true">Tibial Plateau FX</a></li>
<li><a href="https://www.orthobullets.com/trauma/1062/proximal-third-tibia-fracture?expandLeftMenu=true">Proximal Third Tibia Fracture</a></li>
<li><a href="https://www.orthobullets.com/trauma/1045/tibia-shaft-fractures?expandLeftMenu=true">Tibia Shaft FX</a></li>
<li><a href="https://www.orthobullets.com/trauma/1046/tibial-plafond-fractures?expandLeftMenu=true">Tibial Plafond FX</a></li>
</ul>
<br />
<b><br /></b>
<b>Ankle & Hindfoot</b><br />
LITFL: <a href="https://lifeinthefastlane.com/bone-and-joint-bamboozler-001/">https://lifeinthefastlane.com/bone-and-joint-bamboozler-001/</a><br />
Read more on OrthoBullets:<br />
<ul style="text-align: left;">
<li><a href="https://www.orthobullets.com/trauma/1047/ankle-fractures?expandLeftMenu=true">Ankle FX</a></li>
<li><a href="https://www.orthobullets.com/trauma/1048/talar-neck-fractures?expandLeftMenu=true">Talar Neck FX</a></li>
<li><a href="https://www.orthobullets.com/trauma/1049/talus-fracture-other-than-neck?expandLeftMenu=true">Talus Fracture (other than neck)</a></li>
<li><a href="https://www.orthobullets.com/trauma/1050/subtalar-dislocations?expandLeftMenu=true">Subtalar Dislocations</a></li>
<li><a href="https://www.orthobullets.com/trauma/1051/calcaneus-fractures?expandLeftMenu=true">Calcaneus FX</a></li>
</ul>
<br />
<br />
<h3 style="text-align: left;">
References / Resources</h3>
<div>
<ul style="text-align: left;">
<li><b>LifeintheFastLane.com</b></li>
<ul>
<li>Orthopaedics: <a href="http://lifeinthefastlane.com/medical-specialty/orthopedics">lifeinthefastlane.com/medical-specialty/orthopedics</a></li>
<li>Trauma: <a href="http://lifeinthefastlane.com/clinical-cases/trauma-tribulation/">lifeinthefastlane.com/clinical-cases/trauma-tribulation/</a></li>
<li>Hip & Pelvis: <a href="http://lifeinthefastlane.com/hip-and-pelvis-injuries/">lifeinthefastlane.com/hip-and-pelvis-injuries/</a></li>
</ul>
<li><b>OrthoBullets:</b> Trauma - <a href="http://www.orthobullets.com/trauma/1005/evaluation-resuscitation-and-dco">www.orthobullets.com/trauma/1005/evaluation-resuscitation-and-dco</a></li>
<li><b>Royal Children's Hospital</b>: <a href="http://www.rch.org.au/clinicalguide/fractures/">www.rch.org.au/clinicalguide/fractures/</a></li>
<li><b>Radiopedia</b>: Fractures - <a href="http://radiopaedia.org/articles/fracture-1">radiopaedia.org/articles/fracture-1</a></li>
<li><b>ATACC Manual</b>: <a href="http://www.ataccgroup.com/">www.ataccgroup.com/</a></li>
<li><b>Physiopedia</b>: <a href="http://www.physio-pedia.com/">www.physio-pedia.com</a></li>
</ul>
</div>
</div>
</div>
Aaron Sparshotthttp://www.blogger.com/profile/16868086818074290497noreply@blogger.com0tag:blogger.com,1999:blog-4281944981424326587.post-49313670182205319952018-06-26T22:12:00.000+10:002018-06-26T22:21:35.352+10:00REM: Acute Coronary Syndrome<div dir="ltr" style="text-align: left;" trbidi="on">
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Acute Coronary Syndromes have a significant impact on Australian's morbidity and mortality.<br />
Rural Australians have increased rates per capita of cardiovascular disease and poor outcomes post-Myocardial Infarction compared to their Metropolitan counterparts.<br />
<br />
Early recognition followed by access to appropriate reperfusion strategies, plays a key role in improving the outcomes for these patients.<br />
<br />
This is part of the <a href="http://www.ivline.org/2018/06/acrrm-emergency-medicine-study-guide.html">Rural Emergency Module</a> series (designed in particular for ACRRM Trainees).<br />
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<b style="mso-bidi-font-weight: normal;"><span style="color: #ffc000; mso-themecolor: accent4;">Initial Assessment
and Management<o:p></o:p></span></b></h2>
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<span style="color: #e69138;">Consider the diagnosis: Women, the elderly, or Aboriginal/Torres Strait Islander, and patients with diabetes may have atypical presentations.</span><br />
<ul style="text-align: left;">
<li><span style="color: #e69138;"><b>STEMI:</b> ST segment elevations of 1 mm (0.1 mV) in 2 anatomically contiguous leads or 2 mm (0.2 mV) in 2 contiguous precordial leads, OR new left bundle branch block and presentation consistent with ACS. If ECG suspicious but not diagnostic, consult cardiology early.</span></li>
<li><span style="color: #e69138;"><b>Non-STEMI or unstable angina:</b> ST segment depressions or deep T wave inversions without Q waves or possibly no ECG changes</span></li>
</ul>
<br />
<span style="color: #e69138;"><b>Recognition</b></span><br />
<ul style="text-align: left;">
<li><span style="color: #e69138;">Recognise, send for help, gather resources and appropriate equipment. </span></li>
<li><span style="color: #e69138;">Move to resuscitation bay</span></li>
<li><span style="color: #e69138;">Monitoring – telemetry, SpO2</span></li>
<li><span style="color: #e69138;">Early risk-stratification</span></li>
<li><span style="color: #e69138;">Rapid ECG and assessment</span></li>
<li><span style="color: #e69138;">Contact Cardiologist and retrievals if applicable early.</span></li>
</ul>
<span style="color: #e69138;"><br /></span>
<span style="color: #e69138;"><b>Airway</b>:</span><br />
<ul style="text-align: left;">
<li><span style="color: #e69138;">Check airway</span></li>
</ul>
<span style="color: #e69138;"><b>Breathing</b>:</span><br />
<ul style="text-align: left;">
<li><span style="color: #e69138;">If breathing is inadequate, assist with BVM + high flow oxygen</span></li>
<li><span style="color: #e69138;">Avoid routine use of oxygen therapy among patients with SaO2 > 93 %</span></li>
<li><span style="color: #e69138;">COPD patients target SaO2 88-92%, and use oxygen in shocked patients</span></li>
</ul>
<span style="color: #e69138;"><b>Circulation</b>:</span><br />
<ul style="text-align: left;">
<li><span style="color: #e69138;">Assess Pulse, BP (measure both arms -> DDx Aortic Dissection), Cap refill.</span></li>
<li><span style="color: #e69138;">Insert PIVC x2</span></li>
<li><span style="color: #e69138;">Continuous cardiac monitoring</span></li>
<li><span style="color: #e69138;">Give Aspirin 300mg</span></li>
<li><span style="color: #e69138;">Control Blood Pressure; GTN infusion for HTN. B-Blocker (e.g. Metoprolol)</span></li>
<li><span style="color: #e69138;">Assess for and treat left heart failure if present.</span></li>
</ul>
<span style="color: #e69138;"><b>Disability</b>:</span><br />
<ul style="text-align: left;">
<li><span style="color: #e69138;">Determine baseline neurologic function (particularly if fibrinolytic therapy is to be given)</span></li>
<li><span style="color: #e69138;">Altered mental state => evidence of cardiogenic shock</span></li>
</ul>
<span style="color: #e69138;"><b>Exposure</b>:</span><br />
<ul style="text-align: left;">
<li><span style="color: #e69138;">Maintain Normothermia.</span></li>
<li><span style="color: #e69138;">Check bedside Glucose</span></li>
</ul>
<span style="color: #e69138;"><br /></span>
<span style="color: #e69138;"><b>Analgesia + Antiemetics</b></span><br />
<ul style="text-align: left;">
<li><span style="color: #e69138;">Opioid analgesia is preferred to nitrates for the initial control of pain in the setting of STEMI.</span></li>
<li><span style="color: #e69138;">IV morphine boluses titrated to clinical effect.</span></li>
<li><span style="color: #e69138;">If morphine is contraindicated, consider fentanyl at 25 to 50 micrograms IV as initial equivalent dose.</span></li>
</ul>
<span style="color: #e69138;"><br /></span>
<span style="color: #e69138;"><b>Early Interventions to consider</b></span><br />
<ul style="text-align: left;">
<li><span style="color: #e69138;">M orphine / Fentanyl</span></li>
<li><span style="color: #e69138;">O xygen</span></li>
<li><span style="color: #e69138;">N itrates</span></li>
<li><span style="color: #e69138;">A spirin</span></li>
<li><span style="color: #e69138;">R eperfusion (thrombolysis or PCI)</span></li>
<li><span style="color: #e69138;">C lopidegrol / Ticagrelor</span></li>
<li><span style="color: #e69138;">H eparin</span></li>
</ul>
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<b style="mso-bidi-font-weight: normal;"><span style="color: #222a35; mso-themecolor: text2; mso-themeshade: 128;">History</span><o:p></o:p></b></h2>
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<span style="color: #0b5394;"><b>Signs/symptoms</b></span><br />
<ul style="text-align: left;">
<li><span style="color: #0b5394;">Use SOCRATES/PQRRST or preferred assessment of Pain</span></li>
<li><span style="color: #0b5394;">Associated symptoms: nausea/vomiting, sweating, shortness of breath, palpitations, lethargy/fatigue</span></li>
</ul>
<span style="color: #0b5394;"><b>Allergies</b></span><br />
<span style="color: #0b5394;"><b>Meds</b></span><br />
<ul style="text-align: left;">
<li><span style="color: #0b5394;">Anticoagulants, antiplatelets, anti-hyperglycaemics</span></li>
<li><span style="color: #0b5394;">Phosphodiesterase 5 inhibitors e.g. Sildenafil (GTN may have an excessive effect if used)</span></li>
</ul>
<span style="color: #0b5394;"><b>PMHx:</b></span><br />
<ul style="text-align: left;">
<li><span style="color: #0b5394;">Ischaemic Heart Disease, HTN, Diabetes, Smoker, Dyslipidaemia, LV Hypertrophy</span></li>
<li><span style="color: #0b5394;">Renal Function or known impairment</span></li>
<li><span style="color: #0b5394;">Aboriginal & Torres Strait Islander</span></li>
<li><span style="color: #0b5394;">Family Hx</span></li>
<li><span style="color: #0b5394;">Obesity</span></li>
</ul>
<span style="color: #0b5394;"><b>Last oral intake</b></span><br />
<span style="color: #0b5394;"><b>Events</b></span><br />
<ul style="text-align: left;">
<li><span style="color: #0b5394;">Syncope, collapse, cardiac arrest</span></li>
</ul>
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<b style="mso-bidi-font-weight: normal;"><span style="color: #ff33ff;">Investigations</span></b><b style="mso-bidi-font-weight: normal;"><span style="color: #5f0272;"><o:p></o:p></span></b></h2>
</td>
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<ul style="text-align: left;">
<li><span style="color: purple;">FBC, Cardiac Enzymes (Troponin), U&Es, Glu, Coags</span></li>
<li><span style="color: purple;">Serial ECGs (see <a href="http://www.ivline.org/2010/05/quick-guide-to-ecg.html">Quick Guide to ECG</a>)</span></li>
<li><span style="color: purple;">CXR (signs of LV Dysfunction & differential diagnoses)</span></li>
<li><span style="color: purple;">Echocardiography (not routine) / A quick Bedside may provide some further clarification on level of cardiogenic shock, if present</span></li>
</ul>
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<b style="mso-bidi-font-weight: normal;"><span style="color: #009242;">Management<o:p></o:p></span></b></h2>
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</div>
</div>
<br />
<h3 style="text-align: left;">
<span style="color: #6aa84f;">Risk Stratification:</span></h3>
<span style="color: #6aa84f;">Risk stratification will guide urgency for transfer in the context of the patient pre-existing function and location. Note risk stratification here is referring to stratifying severity of suspected/diagnosed ACS, rather than risk stratifying chest pain.</span><br />
<br />
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<br />
<span style="color: #6aa84f;">Queensland Health uses the following general recommendations around timeframes to Angiography.</span><br />
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<ul style="text-align: left;">
<li><span style="color: #6aa84f;"><a href="https://www.mdcalc.com/grace-acs-risk-mortality-calculator">GRACE Score</a></span></li>
<li><span style="color: #6aa84f;"><a href="https://www.mdcalc.com/timi-risk-score-stemi">TIMI Score</a></span></li>
</ul>
<br />
<h3 style="text-align: left;">
<span style="color: #6aa84f;">Antiplatelet Therapy</span></h3>
<ul style="text-align: left;">
<li><span style="color: #6aa84f;">Aspirin 300mg load, 100 – 150 mg daily thereafter.</span></li>
<li><span style="color: #6aa84f;">P2Y12 inhibitors</span></li>
<ul>
<li><span style="color: #6aa84f;">Careful assessment of bleeding risk should be undertaken before using these agents.</span></li>
<li><span style="color: #6aa84f;">Avoid if emergency coronary artery bypass grafting may be required, (e.g. ongoing ischaemia, extensive ECG changes, hemodynamic instability).</span></li>
<li><span style="color: #6aa84f;">Ticagrelor 180 mg loading dose -> 90mg bd. For moderate to high risk NSTEACS treated conservatively or invasively, and STEMI planned for primary PCI. Avoid if emergency coronary artery bypass grafting is likely. Greater proportional benefit in renal impairment (CrCl < 60mL/min)</span></li>
<li><span style="color: #6aa84f;">Clopidogrel 300mg loading dose if thrombolysis planned, 600mg if PCI planned and patient < 75yrs. 75mg daily after loading.</span></li>
<li><span style="color: #6aa84f;">Prasugrel 60mg - may be used in place of clopidogrel in patients with STEMI of less than 12 hours where PCI is planned, or NTEACS after angiography and before PCI.</span></li>
</ul>
</ul>
<span style="color: #6aa84f;">
</span>
<br />
<h3 style="text-align: left;">
<span style="color: #6aa84f;">
Anticoagulants</span></h3>
</div>
<br />
<span style="color: #6aa84f;">Consider availability and appropriateness of agent. Do not switch between agents due increased risk of bleeding.</span><br />
<ul style="text-align: left;">
<li><span style="color: #6aa84f;">Heparin</span></li>
<ul>
<li><span style="color: #6aa84f;">With PCI: Heparin (i.e. “unfractionated”) bolus dose of 5000 units should be given in cases of patients who are to receive PCI for their STEMI.</span></li>
<li><span style="color: #6aa84f;">With fibrin-specific fibrinolysis: Heparin bolus loading dose with the first fibrinolytic dose and then commence heparin infusion</span></li>
</ul>
<li><span style="color: #6aa84f;">Enoxaparin, 1 mg/kg SC (or a reduced dose, 0.75 mg/kg SC in the elderly or those with renal impairment) 12 hourly</span></li>
</ul>
<span style="color: #6aa84f;"><br /></span>
<br />
<h4 style="text-align: left;">
<span style="color: #6aa84f;">
Glycoprotein IIb/IIIa inhibitors</span></h4>
<ul style="text-align: left;">
<li><span style="color: #6aa84f;">Not routinely available in rural hospitals. If available should only be used in consultation with Cardiologist.</span></li>
</ul>
<span style="color: #6aa84f;"><br /></span>
<br />
<h3 style="text-align: left;">
<span style="color: #6aa84f;">
Reperfusion</span></h3>
<span style="color: #6aa84f;"><b>
Indications</b></span><br />
<ul style="text-align: left;">
<li><span style="color: #6aa84f;">All patients who present within 12 hours of symptom onset of STEMI should be considered for a reperfusion strategy, unless they have severe co-morbidities.</span></li>
</ul>
<span style="color: #6aa84f;"><br /><b>
Choice</b><br />
Reperfusion strategy depends upon;</span><br />
<ul style="text-align: left;">
<li><span style="color: #6aa84f;">Duration of symptoms and time to first medical contact</span></li>
<li><span style="color: #6aa84f;">Locally available resources and geography</span></li>
<li><span style="color: #6aa84f;">Time to commence reperfusion strategy</span></li>
<li><span style="color: #6aa84f;">Location of MI</span></li>
<li><span style="color: #6aa84f;">Patient related factors</span></li>
<ul>
<li><span style="color: #6aa84f;">Age</span></li>
<li><span style="color: #6aa84f;">Comorbidities & Risk status</span></li>
<li><span style="color: #6aa84f;">Contraindications to Fibrinolytics</span></li>
</ul>
</ul>
<br />
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<span style="color: #6aa84f;">Fibrinolysis/Thrombolysis</span></h4>
<div class="separator" style="clear: both;">
<span style="color: #6aa84f;">Typically, the only reasonable option available in rural hospitals/medical practices/prehospital. Fibrinolysis typically does not lead to improve outcomes if administered beyond 12hrs, however could be administered in consultation with a Cardiologist.</span></div>
<div class="separator" style="clear: both;">
<span style="color: #6aa84f;"><br /></span></div>
<div class="separator" style="clear: both;">
<span style="color: #6aa84f;"><b>Agents</b></span></div>
<div class="separator" style="clear: both;">
<span style="color: #6aa84f;">There are 3 fibrin-specific fibrinolytic agents available in Australia:</span></div>
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<ul style="text-align: left;">
<li><span style="color: #6aa84f;">tPA (Trade name Alteplase) – Infusion</span></li>
<li><span style="color: #6aa84f;">Tenecteplase (Trade name Metalyse) – Single bolus dose</span></li>
<li><span style="color: #6aa84f;">Reteplase (Trade name Rapilysin) -Two standard bolus doses 30 minutes apart</span></li>
<li><span style="color: #6aa84f;">Streptokinase is no longer used.</span></li>
</ul>
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<span style="color: #6aa84f;">Tenecteplase + Enoxaparin is the lysis of combination of choice. Equivalent if not slightly more effective, similar cost and easiest to use.</span></div>
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<span style="color: #6aa84f;">Taken from <i>Queensland Health Thrombolysis for STEMI Clinical Pathway (2016)</i>. Please review local protocols.</span></div>
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<span style="color: #6aa84f;">Adjunctive Treatment / Supportive Cares </span></h3>
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<span style="color: #6aa84f;">Initiate adjunctive and supportive treatments unless contraindications present.</span></div>
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<span style="color: #6aa84f;">B-Blockers</span></h4>
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<ul style="text-align: left;">
<li><span style="color: #6aa84f;">In a large selection of patients, B-Blockers reduce short-term complications and improve long-term survival.</span></li>
<li><span style="color: #6aa84f;">Recommended orally for both STEMI, and non-STEMI, particularly for hypertension or persistent tachycardia in absence of contraindications, irrespective of other treatment.</span></li>
<li><span style="color: #6aa84f;">If significantly hypertensive, may initiate beta blocker IV instead.</span></li>
<li><span style="color: #6aa84f;">Drug examples; Metoprolol 25 mg orally, Bisoprolol 5-10 mg</span></li>
</ul>
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<span style="color: #6aa84f;">ACEi / ARBs</span></h4>
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<ul style="text-align: left;">
<li><span style="color: #6aa84f;">Postulated to reduce myocardial infarct expansion, ventricular remodeling, and ventricular dilatation</span></li>
<li><span style="color: #6aa84f;">Shown to reduce the risk of death, reinfarction, and hospitalization for congestive heart failure (CHF) post‐acute myocardial infarction</span></li>
<li><span style="color: #6aa84f;">Drug Examples; Catopril, Enalapril, Lisinopril, Rampril</span></li>
<li><span style="color: #6aa84f;">ARBs (e.g. Valsartan) are believed to be a noninferior alternative in ACEI‐intolerant patients.</span></li>
<li><span style="color: #6aa84f;">In Heart Failure with reduced Ejection Fraction (HFrEF) there are newer combination agents (<i>Sacubitril/Valsartan </i>) which may provide additional benefit, but should ideally be started by a Cardiologist or other appropriate specialist.</span></li>
</ul>
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<span style="color: #6aa84f;">Statins</span></h4>
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<ul style="text-align: left;">
<li><span style="color: #6aa84f;">Initiate cholesterol lowering therapy post-MI, unless contraindicated or there is a history of intolerance.</span></li>
<li><span style="color: #6aa84f;">E.g. 80 mg of atorvastatin (best-evidence)</span></li>
</ul>
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<span style="color: #6aa84f;">Supportive – FAST HUGS IN BED Please</span></h4>
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<ul style="text-align: left;">
<li><span style="color: #6aa84f;"><b>Fluid therapy and feeding:</b> Mg >1 , K+ >4</span></li>
<li><span style="color: #6aa84f;"><b>Analgesia, antiemetics: </b>Opioids, Nitrates, Paracetamol. Avoid NSAIDS</span></li>
<li><span style="color: #6aa84f;"><b>Sedation</b>; not routinely indicated</span></li>
<li><span style="color: #6aa84f;"><b>Thromboprophylaxis / Anticoagulation</b>; see above</span></li>
<li><span style="color: #6aa84f;"><b>Head up position</b> (30 degrees) if intubated</span></li>
<li><span style="color: #6aa84f;"><b>Ulcer prophylaxis</b>: Recommended for patients taking DAPT, high-bleeding risk and previous GIT Bleeds. Not required for all patients.</span></li>
<li><span style="color: #6aa84f;"><b>Glucose control:</b> Maintain Normoglycaemia.</span></li>
<li><span style="color: #6aa84f;"><b>Skin/eye care and suctioning</b></span></li>
<li><span style="color: #6aa84f;"><b>Indwelling catheter;</b> not routinely indicated</span></li>
<li><span style="color: #6aa84f;"><b>Nasogastric tube</b>; not routinely indicated</span></li>
<li><span style="color: #6aa84f;"><b>Bowel cares</b></span></li>
<li><span style="color: #6aa84f;"><b>Environment:</b> Maintain Normothermia, remain in monitored environment, transfer to nearest CCU/ICU as applicable.</span></li>
<li><span style="color: #6aa84f;"><b>De-escalation</b> (e.g. end of life issues, treatments no longer needed)</span></li>
<li><span style="color: #6aa84f;"><b>Psychosocial support</b> (for patient, family and staff)</span></li>
</ul>
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<span style="color: #6aa84f;">Life-threatening complications of Acute MI:</span></h4>
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<div>
<ul style="text-align: left;">
<li><span style="color: #6aa84f;"><b>F</b> ailure (heart failure)</span></li>
<li><span style="color: #6aa84f;"><b>E</b> ffusion and tamponade</span></li>
<ul>
<li><span style="color: #6aa84f;"><i>Therapy</i>: pericardiocentesis</span></li>
</ul>
<li><span style="color: #6aa84f;"><b>A</b> rrhythmia (AV block, VT)</span></li>
<ul>
<li><span style="color: #6aa84f;"><i>Therapy</i>: correct hypoxia, acidosis, hypovolaemia, K+ >4, Mg2+ >1</span></li>
</ul>
<li><span style="color: #6aa84f;"><b>R</b> upture</span></li>
<ul>
<li><span style="color: #6aa84f;"><i>Therapy</i>: pericardiocentesis and repair</span></li>
</ul>
<li><span style="color: #6aa84f;"><b>A</b> neurysm (ventricular)</span></li>
<li><span style="color: #6aa84f;"><b>MI</b> (Re-infarction)</span></li>
</ul>
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<div>
<span style="color: #6aa84f;"><br /></span></div>
<div>
<span style="color: #6aa84f;">Complications of therapy, e.g. haemorrhage, coronary artery dissection, stent thrombosis, surgical complications.</span></div>
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<span style="color: #6aa84f;">Overall treatment in Post-MI patients: ABCDE</span></h4>
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<div>
<ul style="text-align: left;">
<li><span style="color: #6aa84f;"><b>A</b> ntiplatelets (Aspirin), ACE inhibitors, Antianginals</span></li>
<li><span style="color: #6aa84f;"><b>B</b> -blocker and Blood pressure control</span></li>
<li><span style="color: #6aa84f;"><b>C </b>holesterol lowering / Cigarette stopping / Cardiac Rehab</span></li>
<li><span style="color: #6aa84f;"><b>D </b>iet and Diabetes control</span></li>
<li><span style="color: #6aa84f;"><b>E </b>ducation and Exercise</span></li>
</ul>
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<h3 style="text-align: left;">
References and Further Resources</h3>
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<li><a href="https://www.ecrjournal.com/articles/evaluation-and-management-st-elevation-myocardial-infarction-and-shock"><span lang="EN-US">https://www.ecrjournal.com/articles/evaluation-and-management-st-elevation-myocardial-infarction-and-shock</span></a></li>
<li><a href="https://www.ncbi.nlm.nih.gov/pubmed/23913604">https://www.ncbi.nlm.nih.gov/pubmed/23913604</a></li>
<li><a href="http://circres.ahajournals.org/content/114/12/1918">http://circres.ahajournals.org/content/114/12/1918</a></li>
<li><a href="https://www.nature.com/articles/s41598-018-20651-">https://www.nature.com/articles/s41598-018-20651-</a>3</li>
<li><a href="http://www.acc.org/latest-in-cardiology/journal-scans/2018/03/08/15/26/mortality-after-coronary-artery-bypass-grafting">http://www.acc.org/latest-in-cardiology/journal-scans/2018/03/08/15/26/mortality-after-coronary-artery-bypass-grafting</a></li>
<li><a href="file:///C:/Users/Aaron/Downloads/anzcor-guideline-14-3-jan16.pdf">anzcor-guideline-14-3-jan16.pdf</a></li>
<li><a href="http://jaha.ahajournals.org/content/6/3/e005165">http://jaha.ahajournals.org/content/6/3/e005165</a></li>
<li><a href="https://lifeinthefastlane.com/ccc/stemi-management/">https://lifeinthefastlane.com/ccc/stemi-management/</a></li>
<li><a href="https://lifeinthefastlane.com/collections/ebm-lecture-notes/chest-pain-adjunctive-therapies/">https://lifeinthefastlane.com/collections/ebm-lecture-notes/chest-pain-adjunctive-therapies/</a></li>
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Aaron Sparshotthttp://www.blogger.com/profile/16868086818074290497noreply@blogger.com0tag:blogger.com,1999:blog-4281944981424326587.post-49623964873476442242018-06-19T10:21:00.001+10:002018-06-26T14:18:01.101+10:00REM: Stroke - Cerebrovascular Accident <div dir="ltr" style="text-align: left;" trbidi="on">
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Cerebrovascular Accidents or Strokes are one of the most common causes of morbidity and mortality in the Western World. People having Strokes will often present through the Emergency Department and as such earlier recognition and timely treatment is crucial in preventing secondary neurological injury.<br />
<br />
This is part of the <a href="http://www.ivline.org/2018/06/acrrm-emergency-medicine-study-guide.html">Rural Emergency Module</a> series (designed in particular for ACRRM Trainees).<br />
<br />
<b>Quick Facts</b><br />
<ul style="text-align: left;">
<li>Stroke is the second commonest cause of death (10-12%)</li>
<li>80-85% are ischaemic (thrombotic or embolic) and 15-20% the more lethal haemorrhagic stroke (including 5% SAH), of which over 50% will die by 1 month.</li>
</ul>
<br />
<b>Aims:</b><br />
<ul style="text-align: left;">
<li>1. Rapid recognition of Symptoms and Diagnosis</li>
<ul>
<li>Prehospital: In people with sudden onset of neurological symptoms a validated tool, such as FAST (Face Arm Speech Test), should be used outside hospital to screen for a diagnosis of stroke or TIA.</li>
<li>Early CT Scan if available within ED (ideally less than 1hr even if outside thrombolysis window)</li>
<li>Identifying Ischaemic vs Haemorrhagic</li>
</ul>
<li>2. Early intervention </li>
<ul>
<li>Antiplatelet Therapy</li>
<li>Thrombolysis (if a candidate within 4.5hrs of stroke onset)</li>
</ul>
<li>3. Specialist care for people with acute stroke</li>
<li>4. Nutrition, hydration and rehabilitation</li>
</ul>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhf-_vGV7iDAwEINh5-iapoJe-oYl0u9Ch_9c0wVPli1xN1x8nDFf-zs0HKZ8Wd83y3rf_asZQBj5IrlfDPdUona2ErzljCvY3u5OM3zbpHiFhxPzeOxoAbNGvxv4K1Uf8DvjqKOTQw0lBy/s1600/Stroke-FAST_genericDigitalbannerV2.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="605" data-original-width="1600" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhf-_vGV7iDAwEINh5-iapoJe-oYl0u9Ch_9c0wVPli1xN1x8nDFf-zs0HKZ8Wd83y3rf_asZQBj5IrlfDPdUona2ErzljCvY3u5OM3zbpHiFhxPzeOxoAbNGvxv4K1Uf8DvjqKOTQw0lBy/s640/Stroke-FAST_genericDigitalbannerV2.png" width="640" /></a></div>
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<b style="mso-bidi-font-weight: normal;"><span style="color: #ffc000; mso-themecolor: accent4;">Initial Assessment
and Management<o:p></o:p></span></b></h2>
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<br />
<b><span style="color: #e69138;">Recognition</span></b><br />
<ul style="text-align: left;">
<li><span style="color: #e69138;">Recognise, send for help, gather resources and appropriate equipment. </span></li>
<li><span style="color: #e69138;">Move to resuscitation bay.</span></li>
<li><span style="color: #e69138;">Continuous Monitoring and observations ideally q15m</span></li>
<li><span style="color: #e69138;">Early liaison with Stroke Specialist through phone or Telemedicine.</span></li>
</ul>
<br />
<span style="color: #e69138;"><b>Airway</b>:</span><br />
<ul style="text-align: left;">
<li><span style="color: #e69138;">Check airway. Manage airway with intubation if concerns regarding airway protection in neurologically impaired patient.</span></li>
<li><span style="color: #e69138;">C-spine protection if any suspicion of con-current trauma.</span></li>
<li><span style="color: #e69138;">Suction for secretions.</span></li>
</ul>
<span style="color: #e69138;"><b>Breathing</b>:</span><br />
<ul style="text-align: left;">
<li><span style="color: #e69138;">If breathing is inadequate, assist with BVM + high flow oxygen in interim. Avoid hyperventilation.</span></li>
<li><span style="color: #e69138;">Correct hypoxia, maintain SpO2 >94%</span></li>
</ul>
<span style="color: #e69138;"><b>Circulation</b>:</span><br />
<ul style="text-align: left;">
<li><span style="color: #e69138;">IV Access</span></li>
<li><span style="color: #e69138;">NBM until further swallow assessment and IV fluids</span></li>
<li><span style="color: #e69138;">Blood pressure control if Systolic BP >200. Avoidance of hypotension equally important.</span></li>
<li><span style="color: #e69138;">ECG & Cardiac Monitoring</span></li>
</ul>
<span style="color: #e69138;"><b>Disability</b>:</span><br />
<ul style="text-align: left;">
<li><span style="color: #e69138;">Level of consciousness – GCS, AVPU</span></li>
<li><span style="color: #e69138;">Check BSL & target normoglycaemia ( < 10mmol)</span></li>
<li><span style="color: #e69138;">Focal neurology</span></li>
<li><span style="color: #e69138;">The three most predictive examination findings for the diagnosis of acute stroke are facial paresis, arm drift/weakness, and abnormal speech.</span></li>
</ul>
<span style="color: #e69138;"><b>Exposure</b>:</span><br />
<ul style="text-align: left;">
<li><span style="color: #e69138;">Check temp, maintain Normothermia.</span></li>
<li><span style="color: #e69138;">Reminder to check bedside BSL + VBG if able</span></li>
<li><span style="color: #e69138;">Correct electrolyte disturbances</span></li>
</ul>
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<div>
<span style="color: #e69138;">Parameters should be optimised in Emergency Department before any formal radiology is done. Note that optimisation does not necessarily equal return to normal function, and definite imaging should not be extensively delayed.</span></div>
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<b style="mso-bidi-font-weight: normal;"><span style="color: #222a35; mso-themecolor: text2; mso-themeshade: 128;">History</span><o:p></o:p></b></h2>
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<span style="color: #3d85c6;"><b>Signs/symptoms</b></span><br />
<ul style="text-align: left;">
<li><span style="color: #3d85c6;">Sudden-onset neurological deficit </span></li>
<li><span style="color: #3d85c6;">Altered level of consciousness</span></li>
<li><span style="color: #3d85c6;">Sudden onset headache + vomiting, favour ICH or SAH compared to ischaemic stroke.</span></li>
</ul>
<span style="color: #3d85c6;"><b>Allergies</b></span><br />
<ul style="text-align: left;">
<li><span style="color: #3d85c6;">To treatments (e.g. aspirin)</span></li>
</ul>
<span style="color: #3d85c6;"><b>Meds </b></span><br />
<ul style="text-align: left;">
<li><span style="color: #3d85c6;">Anticoagulants (causing possible ICH)</span></li>
<li><span style="color: #3d85c6;">Antiepileptics</span></li>
<li><span style="color: #3d85c6;">Recreational drugs, drug withdrawal</span></li>
<li><span style="color: #3d85c6;">Insulin therapy</span></li>
</ul>
<span style="color: #3d85c6;"><b>PMHx:</b></span><br />
<ul style="text-align: left;">
<li><span style="color: #3d85c6;">Prev CVAs, thromboembolic events, Atrial Fibrillation, Carotid stenosis</span></li>
<li><span style="color: #3d85c6;">HTN, Smoker, Dyslipidaemia</span></li>
<li><span style="color: #3d85c6;">Also to consider DDx: epilepsy, drug abuse, recent trauma </span></li>
</ul>
<span style="color: #3d85c6;"><b>Last oral intake</b></span><br />
<span style="color: #3d85c6;"><b>Events</b></span><br />
<ul style="text-align: left;">
<li><span style="color: #3d85c6;">Establishing time-course crucial (will determine if candidate for reperfusion interventions if ischaemic CVA)</span></li>
</ul>
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<b style="mso-bidi-font-weight: normal;"><span style="color: #ff33ff;">Investigations</span></b><b style="mso-bidi-font-weight: normal;"><span style="color: #5f0272;"><o:p></o:p></span></b></h2>
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<span style="color: purple;"><b>Initial</b></span><br />
<ul style="text-align: left;">
<li><span style="color: purple;">VBG – Glucose + Basic Electrolytes + Lactate, +/- POC INR (if on anticoagulants)</span></li>
<li><span style="color: purple;">FBC + Chem20 (U&E + LFTs + Ck + CMP)</span></li>
<li><span style="color: purple;">12-lead ECG (looking in particular for AF)</span></li>
<li><span style="color: purple;">Coagulation Studies</span></li>
<li><span style="color: purple;">Urine Dipstick + Formal M/C/S if indicated</span></li>
<li><span style="color: purple;">CT Head</span></li>
</ul>
<br />
<span style="color: purple;">Also consider in select circumstances and as availability dictates. Bear in mind resources, clinical competence and risks with transfer.</span><br />
<ul style="text-align: left;">
<li><span style="color: purple;">Lipids</span></li>
<li><span style="color: purple;">CXR</span></li>
<li><span style="color: purple;">Lumbar Puncture (if SAH suspected and CT negative)</span></li>
<li><span style="color: purple;">Prothrombotic Screen</span></li>
<li><span style="color: purple;">CT Head and CT Neck Angio, CT Perfusion Studies</span></li>
<li><span style="color: purple;">MRI</span></li>
</ul>
<br />
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<b style="mso-bidi-font-weight: normal;"><span style="color: #009242;">Management<o:p></o:p></span></b></h2>
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<br />
<span style="color: #6aa84f;">Aim is to initiate early treatments and transfer to an appropriate Stroke Facility (ideally within 3hrs). Seek specialist input during early management phase.</span><br />
<span style="color: #6aa84f;"><br /></span>
<span style="color: #6aa84f;">Clarify treatment goals and wishes of patient, bearing in mind acute clinical picture, availability of resources and likely prognosis. Remember Palliative Care principles if a severe deteriorating stroke and not for active management. </span><br />
<span style="color: #6aa84f;"><br /></span>
<span style="color: #6aa84f;">Stroke severity should be assessed and recorded by a health practitioner using a validated tool (e.g. NIHSS).</span><br />
<span style="color: #6aa84f;"><br /></span>
<span style="color: #6aa84f;"><b>Stroke Scores</b></span><br />
<ul style="text-align: left;">
<li><span style="color: #6aa84f;"><a href="https://www.mdcalc.com/modified-nih-stroke-scale-score-mnihss">Modified NIH Stroke Scale/Score (mNIHSS) </a></span></li>
<li><span style="color: #6aa84f;"><a href="https://www.mdcalc.com/nih-stroke-scale-score-nihss">NIH Stroke Scale/Score (NIHSS)</a> </span></li>
<li><span style="color: #6aa84f;"><a href="https://www.blogger.com/(mRS)%20https://www.mdcalc.com/modified-rankin-scale-neurologic-disability">Modified Rankin Scale for Neurologic Disability</a> </span></li>
<li><span style="color: #6aa84f;"><a href="http://www.emed.ie/Neurological/Stroke/Rosier.php">Rule Out Stroke In the Emergency Room (ROSIER)</a> </span></li>
</ul>
<br />
<h4 style="text-align: left;">
<b><span style="color: #6aa84f;">Stroke Pathway</span></b></h4>
<span style="color: #6aa84f; font-size: x-small;">This is an example of a stroke pathway (modified off Logan Hospital Stroke Pathway in Queensland) for patients presenting to the emergency department with a suspected stroke within 24hrs of symptom onset. It assumes that you are constantly reassessing/re-evaluating the patient for ‘stroke mimics’, in which case you would exit the pathway. Note if initial CT Head NAD, shoulder consider DDx + risk-stratify TIA. Transfer to a higher-level facility can occur at any stage, provided ABCDE optimized.</span><br />
<div>
<br /></div>
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<a href="https://4.bp.blogspot.com/-ugSLaxe1hHM/WyD-4Fosl5I/AAAAAAAADP8/B-RZ_U-SZUow4lktoiYQRwqj-9xqsWqBgCLcBGAs/s1600/Stroke%2B-%2Balgorithmn.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="757" data-original-width="600" src="https://4.bp.blogspot.com/-ugSLaxe1hHM/WyD-4Fosl5I/AAAAAAAADP8/B-RZ_U-SZUow4lktoiYQRwqj-9xqsWqBgCLcBGAs/s1600/Stroke%2B-%2Balgorithmn.png" /></a></div>
<div class="separator" style="clear: both; text-align: left;">
<span style="color: #38761d;">The upshot of all this rurally is that our patients may still have time to get to meaningful interventional treatment for their ischaemic neurovascular event. Particularly as more interventional radiology sites come online.</span></div>
<div class="separator" style="clear: both; text-align: left;">
<span style="color: #38761d;"><br /></span></div>
<div>
<h4 style="text-align: left;">
<span style="color: #6aa84f;">
Reperfusion Therapy</span></h4>
<b><span style="color: #6aa84f;">Thrombolysis</span></b><br />
<ul style="text-align: left;">
<li><span style="color: #6aa84f;">Dose is tPA 0.9 mg/kg IV (not to exceed a total 90mg dose, regardless of the patient’s weight). A 10% bolus is given intravenous push over one minute. The remaining 90% is infused over 60 minutes via an infusion pump.</span></li>
<li><span style="color: #6aa84f;">Be aware of Contraindications and exclusion criteria.</span></li>
<li><span style="color: #6aa84f;">Be prepared to manage complications; including ICH.</span></li>
</ul>
<span style="color: #6aa84f;">The evidence for Thrombolysis in Stroke is not as great as for it's use in Myocardial Infarction (STEMIs). It is important that you also have an appropriate discussion of risks/benefits with the patient, be their advocate, and be mindful of the complications of Lysis that <u>YOU</u> might have to end up managing. There are other posts which cover the controversies, however First10EM's post from 2017 is a good place to start </span><span style="color: #6aa84f;"><a href="https://first10em.com/thrombolytics-for-stoke/">https://first10em.com/thrombolytics-for-stoke/</a>.</span><br />
<span style="color: #6aa84f;"><br /></span>
<b><span style="color: #6aa84f;">Neuro-intervention</span></b><br />
<span style="color: #6aa84f;">There is increasing evidence that Endovascular Clot Retrieval (mechanical thrombectomy) can be of benefit to a subset of ischaemic stroke patients. As this is a rapidly evolving area, and a treatment strategy not performed by Rural Generalists only a short overview is provided here.</span><br />
<span style="color: #6aa84f;"><br /></span>
<span style="color: #6aa84f;">Some suggested selection criteria;</span><br />
<ul style="text-align: left;">
<li><span style="color: #6aa84f;">documented large vessel anterior circulation occlusion (middle cerebral artery, M1 or <br />carotid T)</span></li>
<li><span style="color: #6aa84f;">significant clinical deficit at the time of treatment (this might be NIHSS>5 or a lower score that is functionally significant for the patient; note that even mild deficit from proven large vessel occlusion has a high risk of clinical deterioration)</span></li>
<li><span style="color: #6aa84f;">lack of extensive early ischaemic change</span></li>
<li><span style="color: #6aa84f;">pre-stroke functional status and lack of serious comorbidities indicating potential to benefit from treatment (note that age>80 years alone is NOT a contraindication to treatment)</span></li>
<li><span style="color: #6aa84f;">thrombectomy can be performed within 6 to 24hrs</span></li>
<li><span style="color: #6aa84f;">good collateral circulation (though benefit in patients with poor collaterals remains uncertain).</span></li>
</ul>
<span style="color: #6aa84f;"><br /></span>
<span style="color: #6aa84f;">Eligible stroke patients should still receive intravenous thrombolysis while awaiting ECR.</span><br />
<span style="color: #6aa84f;">Eligibility for Neuro-intervention strategies should be discussed in consultation with the appropriate tertiary specialist.</span><br />
<br />
<h4 style="text-align: left;">
<span style="color: #6aa84f;">
Anti-thrombotic Therapy</span></h4>
<span style="color: #6aa84f;">Aspirin 150 – 300mg / day</span><br />
<span style="color: #6aa84f;">Should not be given if;</span><br />
<ul style="text-align: left;">
<li><span style="color: #6aa84f;">Haemorrhagic stroke</span></li>
<li><span style="color: #6aa84f;">Thrombolysed (should not be given within 24 hours of alteplase administration)</span></li>
<li><span style="color: #6aa84f;">Active GI Bleeding</span></li>
<li><span style="color: #6aa84f;">Allergy, intolerance</span></li>
</ul>
<span style="color: #6aa84f;"><br /></span>
<span style="color: #6aa84f;">Addition of dipyridamole 200 mg PO BD</span><br />
<span style="color: #6aa84f;">Consider Clopidogrel as an alternative if aspirin intolerance.</span><br />
<span style="color: #6aa84f;"><br /></span>
<br />
<h4 style="text-align: left;">
<span style="color: #6aa84f;">
Anticoagulation</span></h4>
<ul style="text-align: left;">
<li><span style="color: #6aa84f;">Routine use of anticoagulation in patients without cardioembolism (e.g. atrial fibrillation) following TIA/stroke is not recommended.</span></li>
<li><span style="color: #6aa84f;">Seek specialist input.</span></li>
</ul>
<br />
<h3 style="text-align: left;">
<span style="color: #6aa84f;">
General Principles/Rehab</span></h3>
<h4 style="text-align: left;">
<span style="color: #6aa84f;">
Supportive Cares</span></h4>
<span style="color: #6aa84f;">The underlying aim of stroke management is to restore or maintain homeostasis, The <i>FAST-HUGS-IN-BED-Please</i> is a mnemonic I like to use/consider as part of the initial management of stroke patients, before they commence on more specific rehabilitation strategies.</span><br />
<ul style="text-align: left;">
<li><span style="color: #6aa84f;">Fluid therapy and feeding</span></li>
<li><span style="color: #6aa84f;">Analgesia, antiemetics</span></li>
<li><span style="color: #6aa84f;">Sedation</span></li>
<li><span style="color: #6aa84f;">Thromboprophylaxis</span></li>
<li><span style="color: #6aa84f;">Head position individualise </span></li>
<li><span style="color: #6aa84f;">Ulcer prophylaxis</span></li>
<li><span style="color: #6aa84f;">Glucose control</span></li>
<li><span style="color: #6aa84f;">Skin/eye care and suctioning</span></li>
<li><span style="color: #6aa84f;">Indwelling catheter</span></li>
<li><span style="color: #6aa84f;">Nasogastric tube</span></li>
<li><span style="color: #6aa84f;">Bowel cares</span></li>
<li><span style="color: #6aa84f;">Environment (e.g. temperature control, appropriate surroundings in delirium)</span></li>
<li><span style="color: #6aa84f;">De-escalation (e.g. end of life issues, treatments no longer needed)</span></li>
<li><span style="color: #6aa84f;">Psychosocial support (for patient, family and staff)</span></li>
</ul>
<div>
<span style="color: #6aa84f;"><br /></span>
<span style="color: #6aa84f;">Although typically occurring outside the Emergency Department it is important to remember that coordinated rehabilitation in a Stroke Unit is one of the fundamental management strategies. Specific strategies regarding rehab are outside the scope of this post, but take a look at the <a href="https://informme.org.au/Guidelines/Clinical-Guidelines-for-Stroke-Management-2017">Australian Stroke</a> and <a href="https://www.aan.com/Guidelines/Home/GetGuidelineContent/744">American Stroke</a> Guidelines for more information. </span><br />
<span style="color: #6aa84f;"><br /></span></div>
<h4 style="text-align: left;">
<span style="color: #6aa84f;">
Blood pressure</span></h4>
<ul style="text-align: left;">
<li><span style="color: #6aa84f;">All acute stroke patients should have their blood pressure closely monitored in the first 48 hours after stroke onset.</span></li>
<li><span style="color: #6aa84f;">Patients with acute ischaemic stroke eligible for treatment with intravenous thrombolysis should have their blood pressure reduced to below 185/110 mmHg before treatment and in the first 24 hours after treatment.</span></li>
<li><span style="color: #6aa84f;">Patients with acute ischaemic stroke with blood pressure > 220/120 mmHg should have their blood pressure cautiously reduced (e.g. by no more than 20%) over the first 24 hours</span></li>
</ul>
<span style="color: #6aa84f;"><br /></span>
<br />
<h4 style="text-align: left;">
<span style="color: #6aa84f;">
Cerebral Oedema</span></h4>
<ul style="text-align: left;">
<li><span style="color: #6aa84f;">In stroke patients with brain oedema and raised intracranial pressure, osmotherapy and hyperventilation can be trialled while a neurosurgical consultation is undertaken.</span></li>
</ul>
<br />
<h4 style="text-align: left;">
<span style="color: #6aa84f;">
Swallow Assessment/Screen</span></h4>
<span style="color: #6aa84f;">It is estimated that Dysphagia occurs in between 40-65% of stroke patients. ~50% of the patients with dysphagia go on to aspirate, and 1/3 of patients who aspirate go on to develop pneumonia. The Emergency Department is a common area for Strokes to be diagnosed and essentially your role is to identify whether the patient should be <i>Nil by Mouth (NBM)</i> or <i>able to eat in and drink</i>. </span><br />
<span style="color: #6aa84f;">Swallowing screening tools include a range of tasks including demographics, medical history, global assessment of function, oral mechanism examination, and direct swallowing assessment. </span><br />
<span style="color: #6aa84f;"><br /></span>
<span style="color: #6aa84f;">Some screening tools are listed below;</span><br />
<ul style="text-align: left;">
<li><span style="color: #6aa84f;">ASSIST – Acute Screening of Swallow in Stroke/TIA</span></li>
<li><span style="color: #6aa84f;">RBWH Dysphagia Screening Tool (General and not Stroke Specific)</span></li>
<li><span style="color: #6aa84f;">Toronto Bedside Swallowing Screening Test</span></li>
</ul>
<span style="color: #6aa84f;"><br /></span>
<span style="color: #6aa84f;">Take a look at the above options and find a test that suits your hospital/practice. Alternatively liaise with your Local Speech Pathologist and see what they recommend. Also see <a href="https://onthewards.org/wp-content/uploads/2017/07/Safe-to-swallow.-Assessment-of-the-dysphagic-and-dysphasic-patient-with-Amy-Freeman-Sanderson-final.pdf">Safe to swallow? Assessment of the dysphagic and dysphasic patient</a>.</span><br />
<br />
<span style="color: #6aa84f;">Some simple questions you can ask;</span><br />
<ul style="text-align: left;">
<li><span style="color: #6aa84f;">Is the patient able to:</span></li>
<li><span style="color: #6aa84f;">Maintain alertness for at least 20 minutes? </span></li>
<li><span style="color: #6aa84f;">Maintain posture/positioning in upright sitting?</span></li>
<li><span style="color: #6aa84f;">Hold head erect?</span></li>
<li><span style="color: #6aa84f;">Breath freely, not tachypnoeac (RR>25) and maintain satisfactory oxygenation levels?</span></li>
<li><span style="color: #6aa84f;">Cough effectively/strongly?</span></li>
</ul>
<span style="color: #6aa84f;"><br /></span>
<span style="color: #6aa84f;">A swallow assessed as safe may not remain safe during the length of someone’s admission. Be on guard and reassess. Don't forget nutritional requirements if placing the patient NBM.</span><br />
<span style="color: #6aa84f;"><br /></span>
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<h3 style="text-align: left;">
<span style="color: #6aa84f;">
Intracerebral Hemorrhage Management</span></h3>
<b><span style="color: #6aa84f;">Reverse Anticoagulation Agents if able to do so.</span></b><br />
<ul style="text-align: left;">
<li><span style="color: #6aa84f;">Stroke patients with intracerebral haemorrhage related to direct oral anticoagulants should urgently receive a specific reversal agent where available. (Pollack et al. 2016 [132]; Connolly 2016 [133])</span></li>
</ul>
<b><span style="color: #6aa84f;">Liaise with neurosurgeons for possible surgical intervention.</span></b><br />
<ul style="text-align: left;">
<li><span style="color: #6aa84f;">For selected patients with large (> 3 cm) cerebellar haemorrhage, decompressive surgery should be offered. For other infratentorial haemorrhages (< 3 cm cerebellar, brainstem) the value of surgical intervention is unclear.</span></li>
</ul>
<div>
<span style="color: #6aa84f;"><br /></span></div>
<h3 style="text-align: left;">
<span style="color: #444444; font-weight: normal;">Resources</span></h3>
<div>
<ul style="text-align: left;">
<li><b>Clinical Guidelines for Stroke Management 2017</b></li>
<ul>
<li><a href="https://informme.org.au/Guidelines/Clinical-Guidelines-for-Stroke-Management-2017">https://informme.org.au/Guidelines/Clinical-Guidelines-for-Stroke-Management-2017</a></li>
</ul>
<li><b>Logan Stroke Pathway (image)</b></li>
<li><b>Lifeinthefastlane.com</b></li>
<ul>
<li>Acute Stroke: <a href="https://lifeinthefastlane.com/collections/ebm-lecture-notes/acute-stroke/">https://lifeinthefastlane.com/collections/ebm-lecture-notes/acute-stroke/</a></li>
<li>Stroke Thrombolysis: <a href="https://lifeinthefastlane.com/ccc/stroke-thrombolysis/">https://lifeinthefastlane.com/ccc/stroke-thrombolysis/</a></li>
</ul>
<li><b>ACEM Position statement on IV Thrombolysis for Ischaemic Stroke.</b></li>
<ul>
<li><a href="https://acem.org.au/getmedia/8dca8e1f-4de3-4c28-a2aa-a61400c02650/S129_Statement_on_IV_Thrombolysis_for_Ischaemic_Stroke_v4.aspx">https://acem.org.au/getmedia/8dca8e1f-4de3-4c28-a2aa-a61400c02650/S129_Statement_on_IV_Thrombolysis_for_Ischaemic_Stroke_v4.aspx</a></li>
</ul>
<li><b>Modified NIH Stroke Scale/Score (mNIHSS)</b></li>
<ul>
<li><a href="https://www.mdcalc.com/modified-nih-stroke-scale-score-mnihss">https://www.mdcalc.com/modified-nih-stroke-scale-score-mnihss</a></li>
</ul>
<li><b>Revolution in acute ischaemic stroke care: a practical guide to mechanical thrombectomy</b></li>
<ul>
<li><a href="http://pn.bmj.com/content/early/2017/06/24/practneurol-2017-001685">http://pn.bmj.com/content/early/2017/06/24/practneurol-2017-001685</a></li>
</ul>
<li><b>Dysphagia Screening: State of the Art</b></li>
<ul>
<li><a href="http://stroke.ahajournals.org/content/44/4/e24">http://stroke.ahajournals.org/content/44/4/e24</a></li>
</ul>
</ul>
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Aaron Sparshotthttp://www.blogger.com/profile/16868086818074290497noreply@blogger.com0tag:blogger.com,1999:blog-4281944981424326587.post-69881136364425386972018-06-12T22:38:00.001+10:002020-04-13T10:40:29.308+10:00REM: Acute Traumatic Brain Injury<div dir="ltr" style="text-align: left;" trbidi="on">
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjamiPVl9uMF08MfuUXIpjil2ppN4jaFFhyphenhyphendLQNGblT-b4y7TNLebYOIAuVmDpg-2L7XfbjOdak0IDWycohmby4UP0vK28RdwGa4M29HNyiU_bNGpgoRZGC8YWMFRAJHGnAlHAAgdcxIFI-/s1600/CONCUSSION-facebook.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="800" data-original-width="1600" height="1" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjamiPVl9uMF08MfuUXIpjil2ppN4jaFFhyphenhyphendLQNGblT-b4y7TNLebYOIAuVmDpg-2L7XfbjOdak0IDWycohmby4UP0vK28RdwGa4M29HNyiU_bNGpgoRZGC8YWMFRAJHGnAlHAAgdcxIFI-/s640/CONCUSSION-facebook.jpg" width="2" /></a></div>
The management of Acute Traumatic Brain Injury or Head Trauma can be a significant challenge clinically, resource intensive and influenced by delayed transfer times in Rural Environments. As per Honeybul & Woods (2013), "<span style="background-color: white; font-family: "times new roman" , "stixgeneral" , serif; font-size: 15.9991px;"><span style="color: #666666;"><i>The key initial elements remain aggressive early resuscitation followed by a comprehensive assessment of conscious level and either early consultation or transfer to a neurosurgical facility</i>.</span>"</span><span style="color: #666666;"> </span><br />
<br />
This approach factors in assessing and addressing the Primary Injuries, whilst preventing further Secondary Neurological Injury (through mechanisms such as Hypoxia, Hypotension, Raised ICP, etc).<br />
<br />
This is part of the <a href="http://www.ivline.org/2018/06/acrrm-emergency-medicine-study-guide.html">Rural Emergency Module</a> series (designed in particular for ACRRM Trainees).<br />
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<b style="mso-bidi-font-weight: normal;"><span style="color: #ffc000; mso-themecolor: accent4;">Initial Assessment
and Management<o:p></o:p></span></b></h2>
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<br />
<span style="color: #e69138;">Recognise, send for help, gather resources and appropriate equipment.</span><br />
<span style="color: #e69138;">Move to appropriate area dependent upon severity</span><br />
<span style="color: #e69138;">Monitoring: SpO2, EtCO2, Telemetry</span><br />
<span style="color: #e69138;">Early contact with Retrievals and Neurosurgeons.</span><br />
<span style="color: #e69138;"><br /></span>
<span style="color: #e69138;"><b>Airway</b>:</span><br />
<ul style="text-align: left;">
<li><span style="color: #e69138;">Early intubation in comatosed patients. Tape rather than tie ETT.</span></li>
<li><span style="color: #e69138;">Intubation if agitated (increases ICP), Hypoxia (worsens ischaemia), Hyperventilating (vasoconstriction and decreased CPP)</span></li>
<li><span style="color: #e69138;">Haemorrhage, vomiting and swelling from facial trauma are common causes of airway obstruction in patients with TBI, use suction as necessary.</span></li>
<li><span style="color: #e69138;">Protect the C-Spine – collar/inline immobilisation/sandbags, aim to convert to sandbags to assist venous drainage.</span></li>
<li><span style="color: #e69138;">Avoid NPAs + NGTs.</span></li>
</ul>
<span style="color: #e69138;"><br /></span>
<span style="color: #e69138;"><b>Breathing</b>:</span><br />
<ul style="text-align: left;">
<li><span style="color: #e69138;">Assess depth of breathing and respiratory rate, SpO2 + ETCO2 monitoring</span></li>
<li><span style="color: #e69138;">Correct hypoxia, maintain SpO2 >92%, titrate to blood gases. high flow oxygen 15L/min via a NRB mask</span></li>
<li><span style="color: #e69138;">Aim for PaO2 > 100, PaCO2 ~35, avoid hyperventilation unless immediate risk of coning.</span></li>
</ul>
<br />
<span style="color: #e69138;"><b>Circulation</b>:</span><br />
<ul style="text-align: left;">
<li><span style="color: #e69138;">2x well functioning IVCs</span></li>
<li><span style="color: #e69138;">Control any external haemorrhage</span></li>
<li><span style="color: #e69138;">Normovolaemia and MAP >70, Sys BP >90. </span></li>
<li><span style="color: #e69138;">Use vasopressors as available and treat anaemia with blood products</span></li>
<li><span style="color: #e69138;">Venous Drainage: Head up to 30’ if C-Spine cleared, otherwise whole bed tilt to 15' </span></li>
<li><span style="color: #e69138;">If placing a central line avoid Trendelenburg position.</span></li>
</ul>
<span style="color: #e69138;"><br /></span>
<span style="color: #e69138;"><b>Disability</b>:</span><br />
<ul style="text-align: left;">
<li><span style="color: #e69138;">Monitor patients level of consciousness to help determine the severity of TBI</span></li>
<li><span style="color: #e69138;">Perform and document GCS (AVPU in children), limb movements and pupils regularly. Document prior to sedation/paralysis.</span></li>
<li><span style="color: #e69138;">Early detection of raised ICP, avoid intracranial HTN — sustained ICP > 20mmHg</span></li>
<li><span style="color: #e69138;">Suspect critically raised ICP if; Cushing’s response (Bradycardia, hypertension, apnoeas), fixed and dilated pupils and hemiparesis</span></li>
<li><span style="color: #e69138;">Maintain normoglycaemia (BSL <12)</span></li>
<li><span style="color: #e69138;">Consider early administration anti-epileptics to avoid seizures (Phenytoin or Keppra)</span></li>
</ul>
<span style="color: #e69138;"><br /></span>
<span style="color: #e69138;"><b>Exposure</b>:</span><br />
<ul style="text-align: left;">
<li><span style="color: #e69138;">Assess for other life/limb threatening injuries.</span></li>
<li><span style="color: #e69138;">Maintain normothermia (nil evidence for hypothermia <35 )</span></li>
<li><span style="color: #e69138;">Treat Coagulopathy </span></li>
<li><span style="color: #e69138;">IDC to decrease intra-abdominal pressure and monitor urine output</span></li>
<li><span style="color: #e69138;">Orogastric over Nasogastric tube when and if safe to do so.</span></li>
</ul>
<span style="color: #e69138;"><b>Determining the Severity of TBI</b></span><br />
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<b><span style="color: #e69138;">Glascow Coma Scale</span></b><br />
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<tbody>
<tr>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 260.15pt;" valign="top" width="347"><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm;">
<b><span style="color: #ed7d31; mso-themecolor: accent2;">Evidence of base of skull fracture:<o:p></o:p></span></b></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 260.15pt;" valign="top" width="347"><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm;">
<b><span style="color: #ed7d31; mso-themecolor: accent2;">Evidence of trans-tentorial herniation:<o:p></o:p></span></b></div>
</td>
</tr>
<tr>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 260.15pt;" valign="top" width="347"><div class="MsoListParagraphCxSpFirst" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<span style="color: #ed7d31; mso-themecolor: accent2;">Peri-orbital eccymoses<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<span style="color: #ed7d31; mso-themecolor: accent2;">Retroauricular eccymoses<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<span style="color: #ed7d31; mso-themecolor: accent2;">CSF otorrhoea<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<span style="color: #ed7d31; mso-themecolor: accent2;">CSF rhinorrhoea<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<span style="color: #ed7d31; mso-themecolor: accent2;">Cranial nerve palsies (especially CN VIII)<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<span style="color: #ed7d31; mso-themecolor: accent2;">Haemotympanum<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<span style="color: #ed7d31; mso-themecolor: accent2;"><br /></span></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 260.15pt;" valign="top" width="347"><div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<span style="color: #ed7d31; mso-themecolor: accent2;">Dilated and non-reactive pupils<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<span style="color: #ed7d31; mso-themecolor: accent2;">Asymmetric pupils<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<span style="color: #ed7d31; mso-themecolor: accent2;">Deterioration in neurological condition<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<span style="color: #ed7d31; mso-themecolor: accent2;">Cushing’s reflex: </span><span style="color: #ed7d31; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-themecolor: accent2;">↑</span><span style="color: #ed7d31; mso-themecolor: accent2;"> BP, </span><span style="color: #ed7d31; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-themecolor: accent2;">↓</span><span style="color: #ed7d31; mso-themecolor: accent2;"> HR, Irregular RR<o:p></o:p></span></div>
</td>
</tr>
</tbody></table>
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<tbody>
<tr style="height: 20.45pt; mso-yfti-firstrow: yes; mso-yfti-irow: 0; mso-yfti-lastrow: yes;">
<td style="background: #4472C4; height: 20.45pt; mso-background-themecolor: accent1; padding: 0cm 5.4pt 0cm 5.4pt; width: 450.8pt;" valign="top" width="601"><h2 style="line-height: normal; mso-outline-level: 2;">
<b style="mso-bidi-font-weight: normal;"><span style="color: #222a35; mso-themecolor: text2; mso-themeshade: 128;">History</span><o:p></o:p></b></h2>
</td>
</tr>
</tbody></table>
<br />
<span style="color: #0b5394;"><b>Risk Groups:</b> Elderly, Infants, Anti-coagulated patients, Chronic Alcoholics</span><br />
<span style="color: #0b5394;"><br /></span>
<b><span style="color: #0b5394;">Signs/symptoms</span></b><br />
<ul style="text-align: left;">
<li><span style="color: #0b5394;">Level of consciousness and duration of loss of consciousness, return to level of alertness</span></li>
<li><span style="color: #0b5394;">Amnesia (retrograde, antegrade)</span></li>
<li><span style="color: #0b5394;">Headache, Vomiting, Seizure activity</span></li>
<li><span style="color: #0b5394;">Bleeding or watery drainage from nose or ears</span></li>
<li><span style="color: #0b5394;">Confusion/Agitation</span></li>
<li><span style="color: #0b5394;">Weakness or Parathesia to limbs</span></li>
</ul>
<br />
<b><span style="color: #0b5394;">Allergies</span></b><br />
<span style="color: #0b5394;"><b>Meds</b> </span><br />
<ul style="text-align: left;">
<li><span style="color: #0b5394;">Anticoagulants, antiplatelets, antiepileptics</span></li>
</ul>
<br />
<span style="color: #0b5394;"><b>PMHx</b>:</span><br />
<ul style="text-align: left;">
<li><span style="color: #0b5394;">Epilepsy, Diabetes and other significant co-morbidities</span></li>
<li><span style="color: #0b5394;">Alcohol / Drug Abuse</span></li>
<li><span style="color: #0b5394;">Previous neurosurgery</span></li>
<li><span style="color: #0b5394;">Occupation.</span></li>
</ul>
<br />
<b><span style="color: #0b5394;">Last oral intake</span></b><br />
<b><span style="color: #0b5394;">Events</span></b><br />
<ul style="text-align: left;">
<li><span style="color: #0b5394;">Mechanism of injury, time of injury, site of injury, degree of trauma; including multi-trauma, </span></li>
<li><span style="color: #0b5394;">Alcohol or other intoxicants</span></li>
<li><span style="color: #0b5394;">Preceding signs/symptoms (indicating a precipitating case prior to head injury – e.g. hypoglycaemia, MI)</span></li>
<li><span style="color: #0b5394;">Cardiovascular status and response to treatment to date.</span></li>
</ul>
<span style="color: #cc0000;"><b>Red Flags</b></span><br />
<br />
<ul style="text-align: left;">
<li><span style="color: #cc0000;">High energy transfers</span></li>
<li><span style="color: #cc0000;">Low level of consciousness at presentation</span></li>
<li><span style="color: #cc0000;">Anticoagulation</span></li>
<li><span style="color: #cc0000;">Duration of Coma</span></li>
<li><span style="color: #cc0000;">Diffuse injury on CT</span></li>
<li><span style="color: #cc0000;">Hypotension</span></li>
<li><span style="color: #cc0000;">Age</span></li>
</ul>
<br />
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<table border="0" cellpadding="0" cellspacing="0" class="MsoTableGrid" style="border-collapse: collapse; border: none; mso-border-insideh: none; mso-border-insidev: none; mso-padding-alt: 0cm 5.4pt 0cm 5.4pt; mso-yfti-tbllook: 1184;">
<tbody>
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<td style="background: #7030A0; height: 21.95pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 450.8pt;" valign="top" width="601"><h2 style="line-height: normal; mso-outline-level: 2;">
<b style="mso-bidi-font-weight: normal;"><span style="color: #ff33ff;">Investigations</span></b><b style="mso-bidi-font-weight: normal;"><span style="color: #5f0272;"><o:p></o:p></span></b></h2>
</td>
</tr>
</tbody></table>
<br />
<ul style="text-align: left;">
<li><span style="color: purple;">VBG – PaCO2, Glu, Na derangement</span></li>
<li><span style="color: purple;">FBC, U&Es, INR for anticoagulated patients</span></li>
<li><span style="color: purple;">ECG</span></li>
<li><span style="color: purple;">Cross-match if significant blood loss.</span></li>
<li><span style="color: purple;">Toxicology screen + Blood Alcohol level</span></li>
<li><span style="color: purple;">Associated Trauma Radiology; e.g. FAST Scan, CXR, Pelvic Xray, etc</span></li>
</ul>
<br />
<br />
<b><span style="color: purple;">Neuroimaging</span></b><br />
<span style="color: purple;">CT is the preferred modality if available. If not available prompt transfer to a facility that does, once Primary Assessment and Stabilisation performed. Skull x-rays are not routinely recommended.</span><br />
<span style="color: purple;">See <a href="https://www.ranzcr.com/documents/3832-print-version-adult-head-trauma/file">RANZCR Adult Head Trauma</a> for more details on Modalities and CDRs</span><br />
<span style="color: purple;"><br /></span>
<span style="color: purple;">CT Head/Brain scans are indicated in all Moderate to Severe TBIs. Clinical decision rules can be used to guide selection of patients appropriate for imaging who may initially present as a Mild TBI.</span><br />
<br />
<table border="0" cellpadding="0" cellspacing="0" class="MsoTableGrid" style="border-collapse: collapse; border: none; mso-padding-alt: 0cm 5.4pt 0cm 5.4pt; mso-yfti-tbllook: 1184;">
<tbody>
<tr>
<td style="border-right: solid windowtext 1.0pt; border: none; mso-border-right-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 260.15pt;" valign="top" width="347"><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm;">
<u><span style="color: #dc3afc;">Canadian CT Head Injury/Trauma Rule<o:p></o:p></span></u></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm;">
<i><span style="color: #dc3afc;">High
Risk Criteria<o:p></o:p></span></i></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 17.85pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<span style="color: #ff33ff; font-family: "symbol"; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="font-family: "times new roman"; font-size: 7pt; font-stretch: normal; line-height: normal;"> </span></span><!--[endif]--><span style="color: #dc3afc;">GCS </span><<span style="color: #dc3afc; text-indent: -18pt;">15 at 2
hours post-injury</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 17.85pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<span style="color: #dc3afc;">Suspected open or
depressed skull fracture<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 17.85pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<span style="color: #dc3afc;">Any sign of
basilar skull fracture?<br />
</span><span style="color: #dc3afc; font-size: 10.0pt;">Hemotympanum, raccoon
eyes, Battle’s Sign, CSF oto-/rhinorrhoea</span><span style="color: #dc3afc;"><o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 17.85pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<span style="color: #dc3afc;">≥ 2 episodes of
vomiting<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 17.85pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<span style="color: #dc3afc;">Age ≥ 65<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 17.85pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<span style="color: #dc3afc;"><br /></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: -.15pt; margin-right: 0cm; margin-top: 0cm;">
<i><span style="color: #dc3afc;">Medium Risk
Criteria<o:p></o:p></span></i></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 17.85pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<span style="color: #dc3afc;">Retrograde amnesia
to the event ≥ 30 minutes<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 17.85pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<span style="color: #ff33ff; font-family: "symbol"; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="font-family: "times new roman"; font-size: 7pt; font-stretch: normal; line-height: normal;"> </span></span><!--[endif]--><span style="color: #dc3afc;">“Dangerous”
mechanism?<br />
</span><span style="color: #dc3afc; font-size: 10.0pt;">Pedestrian struck by
motor vehicle, occupant ejected from motor vehicle, or fall from > 3 feet
or > 5 stairs.</span><span style="color: #dc3afc;"><o:p></o:p></span></div>
</td>
<td style="border: none; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 260.15pt;" valign="top" width="347"><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 12.8pt; margin-right: 0cm; margin-top: 0cm;">
<u><span style="color: #dc3afc;">NEXUS II<o:p></o:p></span></u></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 12.8pt; margin-right: 0cm; margin-top: 0cm;">
<span style="color: #dc3afc;">If any of the following are present, CT is required.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 12.8pt; margin-right: 0cm; margin-top: 0cm;">
<span style="color: #dc3afc;">If none are present, CT is not required:<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto; mso-list: l1 level1 lfo1; text-indent: -18.0pt;">
<span style="color: #ff33ff; font-family: "symbol"; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="font-family: "times new roman"; font-size: 7pt; font-stretch: normal; line-height: normal;"> </span></span><!--[endif]--><span style="color: #dc3afc;">evidence of
significant skull fracture<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto; mso-list: l1 level1 lfo1; text-indent: -18.0pt;">
<span style="color: #ff33ff; font-family: "symbol"; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="font-family: "times new roman"; font-size: 7pt; font-stretch: normal; line-height: normal;"> </span></span><span style="color: #dc3afc;">scalp haematoma<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto; mso-list: l1 level1 lfo1; text-indent: -18.0pt;">
<span style="color: #ff33ff; font-family: "symbol"; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="font-family: "times new roman"; font-size: 7pt; font-stretch: normal; line-height: normal;"> </span></span><!--[endif]--><span style="color: #dc3afc;">neurologic deficit<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto; mso-list: l1 level1 lfo1; text-indent: -18.0pt;">
<span style="color: #ff33ff; font-family: "symbol"; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="font-family: "times new roman"; font-size: 7pt; font-stretch: normal; line-height: normal;"> </span></span><!--[endif]--><span style="color: #dc3afc;">altered level of
alertness<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto; mso-list: l1 level1 lfo1; text-indent: -18.0pt;">
<span style="color: #ff33ff; font-family: "symbol"; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="font-family: "times new roman"; font-size: 7pt; font-stretch: normal; line-height: normal;"> </span></span><!--[endif]--><span style="color: #dc3afc;">abnormal behaviour<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto; mso-list: l1 level1 lfo1; text-indent: -18.0pt;">
<span style="color: #ff33ff; font-family: "symbol"; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="font-family: "times new roman"; font-size: 7pt; font-stretch: normal; line-height: normal;"> </span></span><!--[endif]--><span style="color: #dc3afc;">coagulopathy<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto; mso-list: l1 level1 lfo1; text-indent: -18.0pt;">
<span style="color: #dc3afc;">persistent
vomiting<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto; mso-list: l1 level1 lfo1; text-indent: -18.0pt;">
<span style="color: #ff33ff; font-family: "symbol"; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="font-family: "times new roman"; font-size: 7pt; font-stretch: normal; line-height: normal;"> </span></span><!--[endif]--><span style="color: #dc3afc;">age 65 years or
more<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm;">
<br /></div>
</td>
</tr>
</tbody></table>
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://www.ranzcr.com/documents/3832-print-version-adult-head-trauma/file"><img border="0" data-original-height="428" data-original-width="600" src="https://3.bp.blogspot.com/-9lywxgcVTxA/WyDIf_rNaKI/AAAAAAAADO8/kuzzVBhzKpMHZeu5aBjeE7eOwcvHmFAagCLcBGAs/s1600/RANZCR%2B-%2BCCHR%2B-%2BAdults.gif" /></a></div>
<div style="text-align: center;">
<span style="font-size: x-small;">Click to see more details from <a href="https://www.ranzcr.com/documents/3832-print-version-adult-head-trauma/file">RANZCR Guidelines - Adult Head Trauma</a>.</span></div>
<br />
<span style="color: purple;"><b>Paediatric Patients</b></span><br />
<span style="color: purple;">Use the PECARN rule – however other rules exist.</span><br />
<span style="color: purple;">Inclusion criteria (ALL must be satisfied if PECARN algorithm to be applied):</span><br />
<ul style="text-align: left;">
<li><span style="color: purple;">Age < 18 years old.</span></li>
<li><span style="color: purple;">GCS 14 or 15.</span></li>
<li><span style="color: purple;">Presented to ED within 24 hours of head trauma (blunt)</span></li>
</ul>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://www.ranzcr.com/documents/3839-print-version-paediatric-head-trauma/file"><img border="0" data-original-height="360" data-original-width="520" src="https://4.bp.blogspot.com/-0RqIHa-aVQA/WyDIZCaifGI/AAAAAAAADO0/H8OrZ8cfE7AMDgx6yDDaKE_v2Bu1UirwgCLcBGAs/s1600/RANZCR%2B-%2BPECARN%2BRule%2BA.gif" /></a></div>
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://www.ranzcr.com/documents/3839-print-version-paediatric-head-trauma/file"><img border="0" data-original-height="360" data-original-width="520" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhGo30Z1_g92YkVnTkO67iUtv0Hb7sJ4wLltQBAbWIiDl669GUXoKlgqZpstK26azyXRRv4RCQwK7REYsjdQuByJMRX2gdLTtjgw9UvkR53r2yaPplOi5xhwwS7QOaQpWvHcZVj4XbPt8IQ/s1600/RANZCR+-+PECARN+Rule+B.gif" /></a></div>
<div style="text-align: center;">
<span style="font-size: x-small;">Click to see more details from <a href="https://www.ranzcr.com/documents/3839-print-version-paediatric-head-trauma/file">RANZCR Guidelines - Paediatric Head Trauma</a>.</span></div>
<div>
<span style="color: purple;"><br /></span>
<span style="color: purple;"><a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30555-X/fulltext">Accuracy of PECARN, CATCH, and CHALICE head injury decision rules in children</a> in the context of Australia </span><span style="color: purple;">was reviewed </span><span style="color: purple;">in the Lancet in 2017. </span><br />
<span style="color: purple;"><br /></span></div>
<span style="color: purple;">Cranial Ultrasound could be considered in infants if limited radiology modalities available in the interim. Note ICH will only be able to be assessed in children < 1y age with open fontanelles. In older children it can be used to assess for Skull Fractures with significant limitations.</span><br />
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<b style="mso-bidi-font-weight: normal;"><span style="color: #009242;">Management<o:p></o:p></span></b></h2>
</td>
</tr>
</tbody></table>
<br />
<div>
<div>
<span style="color: #6aa84f;">Need to consider primary injury management in conjunction with ABCDE priorities, and secondary injury management. Frequent reassessment is crucial to ensure early signs of raised ICP are not missed.</span></div>
<div>
<span style="color: #6aa84f;"><br /></span></div>
<h4 style="text-align: left;">
<span style="color: #6aa84f;">Physiological and Biochemical Targets:</span></h4>
<div>
<ul style="text-align: left;">
<li><span style="color: #6aa84f;">PaO2 >100 mmHg, PaCO2 ~35 mmHg </span></li>
<li><span style="color: #6aa84f;">Temp 36-37C,</span></li>
<li><span style="color: #6aa84f;">MAP>70 mmHg (CPP 50-70 mmHg if ICP monitor is placed)</span></li>
<li><span style="color: #6aa84f;">Maintaining SBP at 50 to 69 yo: >100 mmHg | 15-49 or >70 years: >110 mmHg or above for patients, may improve outcomes.</span></li>
<li><span style="color: #6aa84f;">Glucose 6 – 10 mmol/L</span></li>
<li><span style="color: #6aa84f;">Treating ICP >22 mm Hg is recommended because values above this level are associated with ↑ mortality</span></li>
<li><span style="color: #6aa84f;">Monitoring should occur at least every 15 minutes until the retrieval/transfer team arrival</span></li>
</ul>
</div>
<div>
<br /></div>
<h4 style="text-align: left;">
<span style="color: #6aa84f;">General Supportive Principles</span></h4>
<div>
<span style="color: #6aa84f;">As always keep FAST HUGS in BED Please in the back of your mind.</span></div>
<div>
<ul style="text-align: left;">
<li><span style="color: #6aa84f;"><b>Nutrition</b>: feed patients at least by day five -> decreases mortality</span></li>
<li><span style="color: #6aa84f;"><b>Sedation and analgesia:</b> reduce cerebral oxygen demand, and prevent coughing and straining; both of which increase ICP</span></li>
<ul>
<li><span style="color: #6aa84f;">Propofol often a favoured sedation agent.</span></li>
<li><span style="color: #6aa84f;">Short-acting analgesic agents are the best choice if the patient is to remain spontaneously breathing, so as not to hinder GCS assessment</span></li>
</ul>
<li><span style="color: #6aa84f;"><b>Anti-emetics</b>: coughing and straining increases ICP, also important to reduce risks during patient transfer</span></li>
<li><span style="color: #6aa84f;"><b>Antibiotics</b>: Antibiotic prophylaxis should occur in all cases of open and penetrating injuries as well as when there is suspicion of any base of skull fractures. Tetanus prophylaxis should be administered in any penetrating brain injury patients.</span></li>
<li><span style="color: #6aa84f;"><b>Thromboprophylaxis</b>: Insufficient evidence for pharmacological agents. LMWH or low-dose unfractioned heparin may be used in combination with mechanical prophylaxis. However, there is an increased risk for expansion of intracranial haemorrhage.</span></li>
<li><span style="color: #6aa84f;"><b>Head up position </b>(30 degrees)</span></li>
<li><span style="color: #6aa84f;"><b>Ulcer prophylaxis</b></span></li>
<li><span style="color: #6aa84f;"><b>Glucose control:</b> aim for BSL between 6-10 mmol</span></li>
<li><span style="color: #6aa84f;"><b>Skin/eye care and suctioning</b>: Clean, debride, bandage and dress wounds as appropriate. Steps in the initial management should focus on control of external haemorrhage. If direct pressure fails to achieve haemostasis, than stapling and suturing should be considered.</span></li>
<li><span style="color: #6aa84f;"><b>Indwelling catheter</b>: to decrease intra-abdominal pressure and monitor urine output</span></li>
<li><span style="color: #6aa84f;"><b>Nasogastric tube</b>: orogastric is the preferred option in head trauma patients. Should be performed after intubation.</span></li>
<li><span style="color: #6aa84f;"><b>Bowel cares</b></span></li>
<li><span style="color: #6aa84f;"><b>Environment</b>: Maintain Normothermia (Temp 36-37; give antipyretics if Temp >38C) to prevent a rise in cerebral metabolic rate.</span></li>
</ul>
</div>
<div>
<br /></div>
<h4 style="text-align: left;">
<span style="color: #6aa84f;">Hyperventilation:</span></h4>
<div>
<span style="color: #6aa84f;">Used as a rescue therapy to prevent herniation.</span></div>
<div>
<span style="color: #6aa84f;">Reduces ICP at the expense of Cerebral Blood Flow.</span></div>
<div>
<ul style="text-align: left;">
<li><span style="color: #6aa84f;">Aim for PaCO2 30mmHg</span></li>
<li><span style="color: #6aa84f;">Monitor with EtCO2 readings or ABG.</span></li>
</ul>
</div>
<div>
<span style="color: #6aa84f;">Prolonged Hyperventilation should be avoided during the first 24 h after injury when CBF often is reduced critically.</span></div>
<div>
<span style="color: #6aa84f;"><br /></span></div>
<h4 style="text-align: left;">
<span style="color: #6aa84f;">Intubation Considerations:</span></h4>
<div>
<span style="color: #6aa84f;">The approach to intubation in head trauma patients should include optimising physiological parameters, maintenance of those parameters, preventing reflex sympathetic response and minimising complications of intubation. </span></div>
<div>
<span style="color: #6aa84f;"><br /></span></div>
<div>
<span style="color: #6aa84f;">See Intubation of the Neurocritical Care Patient for further details; <a href="https://lifeinthefastlane.com/ccc/intubation-of-the-neurocritical-care-patient/">https://lifeinthefastlane.com/ccc/intubation-of-the-neurocritical-care-patient/</a>.</span></div>
<div>
<span style="color: #6aa84f;"><br /></span></div>
<div>
<u><span style="color: #6aa84f;">One suggested approach:</span></u></div>
<div>
<ul style="text-align: left;">
<li><span style="color: #6aa84f;">Ensure adequate preoxygenation and use apnoeic oxygenation</span></li>
<li><span style="color: #6aa84f;"><b>Pre-treatment:</b> IV Fentanyl + topical lignocaine (e.g. 5 ml of 4% lidocaine spray) effectively attenuates cardiovascular responses to intubation.</span></li>
<li><span style="color: #6aa84f;"><b>Induction Agent:</b> Minimal or no induction dose. Propofol or thiopentone or ketamine. Be aware of Pros/Cons of each agent.</span></li>
<li><span style="color: #6aa84f;"><b>Paralytic:</b> IV Rocuronium 1.2 mg/kg is agent of choice. Avoid Suxamethonium where possible.</span></li>
</ul>
</div>
<div>
<br /></div>
<h4 style="text-align: left;">
<span style="color: #6aa84f;">Osmotherapy:</span></h4>
<div>
<span style="color: #6aa84f;">Used as a rescue therapy to prevent herniation.</span></div>
<div>
<span style="color: #6aa84f;">The evidence around osmotherapy is still of insufficient quality and quantity to determine which intervention offers the best outcome for patients with Severe TBI. Treatment choice should be guided by available fluid therapy and with specialist input. </span></div>
<div>
<ul style="text-align: left;">
<li><span style="color: #6aa84f;"><b>Mannitol (20%):</b></span></li>
<ul>
<li><span style="color: #6aa84f;">Maximal effect within 20 – 40 minutes</span></li>
<li><span style="color: #6aa84f;">Dose: 0.25-1g/kg over 5-10 minutes</span></li>
<li><span style="color: #6aa84f;">May result in; worsening hypovolaemia, renal failure. May also require inotropic support.</span></li>
</ul>
<li><span style="color: #6aa84f;"><b>Hypertonic Saline (3%):</b></span></li>
<ul>
<li><span style="color: #6aa84f;">Dose: 6-8 ml/kg of 3% solution as a bolus.</span></li>
<li><span style="color: #6aa84f;">Useful in hypovolaemic patients as increases circulating volume, compared to Mannitol</span></li>
<li><span style="color: #6aa84f;">Tends to last longer than Mannitol.</span></li>
</ul>
<li><span style="color: #6aa84f;"><b>Sodium Bicarbonate: </b></span></li>
<ul>
<li><span style="color: #6aa84f;">No 3% hypertonic saline/mannitol in your facility, you could consider using sodium bicarbonate.</span></li>
<li><span style="color: #6aa84f;">8.4% bicarbonate for osmotherapy may be conceptualized as “6% saline.</span></li>
<li><span style="color: #6aa84f;">Suggested Dose (adults): 80-120 ml or two 50ml ampules of 8.4% sodium bicarbonate over 30 minutes. </span></li>
</ul>
</ul>
</div>
<div>
<br /></div>
<h4 style="text-align: left;">
<span style="color: #6aa84f;">Seizure Management / Prophylaxis</span></h4>
<div>
<span style="color: #6aa84f;">If seizures a useful mantra is Sedate, Intubate, Ventilate.</span></div>
<div>
<span style="color: #6aa84f;">Follow normal seizure management protocol.</span></div>
<div>
<span style="color: #6aa84f;">Load the patient with an anticonvulsant such as Phenytoin or Keppra (levetiracetam). </span></div>
<div>
<span style="color: #6aa84f;"><br /></span></div>
<div>
<span style="color: #6aa84f;">Phenytoin prophylaxis is recommended to decrease the incidence of early PTS (within 7 d of injury), when the overall benefit is thought to outweigh the complications associated with such treatment. There is insufficient evidence currently regarding the use of Keppra (levetiracetam) for prophylaxis, but it is also likely to be beneficial and is used by several Australian Health Services.</span></div>
<div>
<span style="color: #6aa84f;"><br /></span></div>
<div>
<h4 style="text-align: left;">
<span style="color: #6aa84f;">Burr Hole Evacuation</span></h4>
<div>
<span style="color: #6aa84f;">This procedure is especially important in a patient who is rapidly deteriorating and does not respond to non-surgical measures. Consult with neurosurgeon and use Telehealth as available. </span></div>
<div>
<ul style="text-align: left;">
<li><span style="color: #6aa84f;"><b>Indications</b>: Patient with reduced GCS (< 8) with imaging evidence of an extra-dural haematoma causing midline shift and unequal pupils when timely neurosurgical intervention is not possible.</span></li>
<li><span style="color: #6aa84f;"><b>Contradictions</b>: GCS > 8, Neurosurgical intervention available in a reasonable time frame, No Imaging (exception to this is where significant imaging delays exist and high clinical suspicion of injury)</span></li>
<li><span style="color: #6aa84f;"><b>Further Considerations:</b> level of surgical experience and range of neurosurgical equipment available at the hospital.</span></li>
<li><span style="color: #6aa84f;"><b>Procedure</b>: see <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3352313">Emergency burr holes: "How to do it"</a> / and <a href="https://www.nsa.org.au/Documents/Information/Rural%20and%20Remote%20Trauma.pdf">The Management of Acute Neurotrauma in Rural and Remote Locations</a> section on Burr Holes for further details.</span></li>
</ul>
</div>
<div>
<br /></div>
<h4 style="text-align: left;">
<span style="color: #6aa84f;">Anticoagulation reversal and Antifibrinolytics</span></h4>
<div>
<span style="color: #6aa84f;"><b>Reversal of anticoagulation agents</b></span><br />
<ul style="text-align: left;">
<li><span style="color: #6aa84f;">Any patient who is taking an anticoagulant such as warfarin or other oral anticoagulants (dabigatran, rivaroxaban, apixaban) is at high risk of developing significant bleeds intracranially and elsewhere.</span></li>
<li><span style="color: #6aa84f;">Reversal should be considered in liaison with surgeons and/or haematologist</span></li>
</ul>
<br /></div>
<div>
<span style="color: #6aa84f;"><b>Tranexamic Acid</b></span></div>
<div>
<ul style="text-align: left;">
<li><span style="color: #6aa84f;">Insufficient evidence to recommend routine administration of Tranexamic Acid solely for TBI.</span></li>
</ul>
</div>
<div>
<br />
<h4 style="text-align: left;">
References/Further Resources</h4>
<ul style="text-align: left;">
<li><b>Lifeinthefastlane</b></li>
<ul>
<li><a href="https://lifeinthefastlane.com/ccc/traumatic-brain-injury/">https://lifeinthefastlane.com/ccc/traumatic-brain-injury/</a></li>
<li><a href="https://lifeinthefastlane.com/ccc/traumatic-brain-injury-tbi-management/">https://lifeinthefastlane.com/ccc/traumatic-brain-injury-tbi-management/</a></li>
</ul>
<li><b>Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition</b></li>
<ul>
<li>Summary: <a href="https://braintrauma.org/uploads/07/04/Guidelines_for_the_Management_of_Severe_Traumatic.97250__2_.pdf">https://braintrauma.org/uploads/07/04/Guidelines_for_the_Management_of_Severe_Traumatic.97250__2_.pdf</a></li>
<li>Full Guideline: <a href="https://braintrauma.org/uploads/03/12/Guidelines_for_Management_of_Severe_TBI_4th_Edition.pdf">https://braintrauma.org/uploads/03/12/Guidelines_for_Management_of_Severe_TBI_4th_Edition.pdf</a></li>
</ul>
<li><b>Victorian Traumatic Brain Injury Guideline</b></li>
<ul>
<li><a href="http://trauma.reach.vic.gov.au/sites/default/files/Traumatic%20Brain%20Injury%20Guideline%20Guideline_Ver%201.0_250914_complete.pdf">http://trauma.reach.vic.gov.au/sites/default/files/Traumatic%20Brain%20Injury%20Guideline%20Guideline_Ver%201.0_250914_complete.pdf</a></li>
</ul>
<li><b>The Management of Acute Neurotrauma in Rural and Remote Locations</b></li>
<ul>
<li><a href="https://www.nsa.org.au/Documents/Information/Rural%20and%20Remote%20Trauma.pdf">https://www.nsa.org.au/Documents/Information/Rural%20and%20Remote%20Trauma.pdf</a></li>
</ul>
<li><b>RANZCR</b></li>
<ul>
<li>Adults: <a href="https://www.ranzcr.com/documents/3832-print-version-adult-head-trauma/file">https://www.ranzcr.com/documents/3832-print-version-adult-head-trauma/file</a></li>
<li>Children/Paediatrics: <a href="https://www.ranzcr.com/documents/3839-print-version-paediatric-head-trauma/file">https://www.ranzcr.com/documents/3839-print-version-paediatric-head-trauma/file</a></li>
</ul>
<li><b>Initial management of traumatic brain injury in the rural setting</b></li>
<ul>
<li><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3579040/">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3579040/</a></li>
</ul>
<li><b>Intubation of the Neurocritical Care Patient</b></li>
<ul>
<li><a href="https://lifeinthefastlane.com/ccc/intubation-of-the-neurocritical-care-patient/">https://lifeinthefastlane.com/ccc/intubation-of-the-neurocritical-care-patient/</a></li>
</ul>
</ul>
<br />
<br />
<br />
<br /></div>
</div>
<div>
<br /></div>
</div>
</div>
</div>
Aaron Sparshotthttp://www.blogger.com/profile/16868086818074290497noreply@blogger.com0tag:blogger.com,1999:blog-4281944981424326587.post-65092502187648310352018-06-12T22:10:00.001+10:002018-08-08T21:14:38.710+10:00ACRRM Emergency Medicine Study Guide<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="separator" style="clear: both; text-align: center;">
<a href="https://1.bp.blogspot.com/-SPw0admD2fY/WxE2VDNVi0I/AAAAAAAADNY/PjGfX501iegIxoIuAwYYmZ_XjgayY4mPACLcBGAs/s1600/canola_fields_green_rolling_hills_agriculture_farm_landscape_crop_summer-1361384%2B%25281%2529.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="714" data-original-width="1200" height="1" src="https://1.bp.blogspot.com/-SPw0admD2fY/WxE2VDNVi0I/AAAAAAAADNY/PjGfX501iegIxoIuAwYYmZ_XjgayY4mPACLcBGAs/s640/canola_fields_green_rolling_hills_agriculture_farm_landscape_crop_summer-1361384%2B%25281%2529.jpg" width="1" /></a></div>
<br />
<br />
The aim of this guide is provide an approach and resources to those intending to work as Rural Generalists and in particular registrars preparing for assessment in the Emergency Medicine Advanced Skill through the <a href="http://www.acrrm.org.au/training-towards-fellowship/curriculum-and-requirements/advanced-specialised-training">Australian College of Rural and Remote Medicine</a> (ACRRM).<br />
<br />
Note it is not the official work of ACRRM, but rather a collection of self-made and FOAMed Resources from across the web.<br />
<br />
<h3 style="text-align: left;">
Official Resources</h3>
Please always check <a href="https://www.acrrm.org.au/">ACRRM.org.au</a> to ensure you have the latest information regarding the curriculum and assessment requirements.<br />
<br />
<iframe allowfullscreen="" frameborder="0" height="485" marginheight="0" marginwidth="0" scrolling="no" src="//www.slideshare.net/slideshow/embed_code/key/1PHYwNNlovBH8w" style="border-width: 1px; border: 1px solid #ccc; margin-bottom: 5px; max-width: 100%;" width="595"> </iframe> <br />
<div style="margin-bottom: 5px;">
<strong> <a href="https://www.slideshare.net/akspar/stamps-community-profile-emergency-gem" target="_blank" title="STAMPS Community Profile - Emergency + GEM">STAMPS Community Profile - Emergency + GEM</a> </strong> from <strong><a href="https://www.slideshare.net/akspar" target="_blank">Aaron Sparshott</a></strong> </div>
<br />
<b>Recommended Reading as per ACRRM</b><br />
<ul style="text-align: left;">
<li>Cameron, P et al: Textbook of Adult Emergency Medicine, Edinburgh – Churchill Livingstone.</li>
<li>Cameron, P et al: Textbook of Paediatric Emergency Medicine, Edinburgh – Churchill Livingstone.</li>
<li>Rosen: Emergency Medicine</li>
<li>Tintinalli, J et al: Emergency Medicine, a comprehensive study guide, New York -McGraw-Hill.</li>
<li>ACRRM online learning: www.acrrm.org.au</li>
<li>Bersten A, Soni N, Oh T: Oh’s Intensive Care Manual, Edinburgh - ButterworthHeinemann.</li>
<li>McRae R, Esser M: Practical fracture treatment, Edinburgh - Churchill Livingstone.</li>
<li>Murray L et al: Toxicology Handbook, Sydney - Elsevier</li>
<li>Shann, F: Drug doses, Parkville Vic - Collective.</li>
<li>Australian Medicines Handbook: Drug Choice Companion Emergency Care, Adelaide</li>
<li>Australian Medicines Handbook Pty Ltd.</li>
</ul>
<br />
<div>
<br /></div>
<h3 style="text-align: left;">
STAMPs Proforma</h3>
This is an approach I use to prepare for the formal assessment after receiving the stem. You may also find it useful for preparing responses, however feel free to adapt it as you see fit.<br />
<br />
<iframe allowfullscreen="" frameborder="0" height="485" marginheight="0" marginwidth="0" scrolling="no" src="//www.slideshare.net/slideshow/embed_code/key/xFlkfa7j4yy3P1" style="border-width: 1px; border: 1px solid #ccc; margin-bottom: 5px; max-width: 100%;" width="595"> </iframe> <br />
<div style="margin-bottom: 5px;">
<strong> <a href="https://www.slideshare.net/akspar/acrrm-stamps-proforma" target="_blank" title="ACRRM STAMPs proforma">ACRRM STAMPs proforma</a> </strong> from <strong><a href="https://www.slideshare.net/akspar" target="_blank">Aaron Sparshott</a></strong> </div>
<br />
<h3 style="text-align: left;">
STAMPS Study Guide</h3>
The following topics which will be covered progressively in this guide. The study guide is largely structured to address aspects of the ACRRM STAMPS Proforma above. Topics which are available for reading will have: Topic - current as of <i>date.</i><br />
<br />
<h4 style="text-align: left;">
Airway</h4>
Severe Asthma<br />
Tension Pneumothorax<span style="white-space: pre;"> </span><br />
Pneumothorax<br />
Anaphylaxis and Allergies (including ASCIA guidelines)<br />
Acute Pulmonary Oedema<br />
Pneumonia<br />
<br />
<h4 style="text-align: left;">
Cardiology</h4>
Acute Coronary Syndrome<br />
<ul>
<li><span style="color: #38761d;"><a href="http://www.ivline.org/2018/06/rem-acute-coronary-syndrome.html"><span style="color: #38761d;">STEMI/NTSTEMI</span></a> - current as of June 2018</span></li>
<li><span style="color: #38761d;"><a href="http://www.ivline.org/2018/06/rem-acute-coronary-syndrome.html"><span style="color: #38761d;">Thrombolytics for AMI</span></a> <span style="color: #38761d;">- current as of June 2018</span></span></li>
<li><span style="color: #38761d;"><a href="http://www.ivline.org/2018/06/rem-acute-coronary-syndrome.html"><span style="color: #38761d;">Contraindications to Thrombolysis</span></a> <span style="color: #38761d;">- current as of June 2018</span></span></li>
<li>Sgarbossa Criteria (AMI w/ LBBB)</li>
<li>Chest Pain Descriptors Associated With AMI</li>
<li>Chest Pain Risk Stratification</li>
<li>TIMI Score / Risk</li>
</ul>
An Approach to Syncope<br />
<ul style="text-align: left;">
<li>San Francisco Syncope Rule (“CHESS” mnemonic)</li>
<li>ECG in Syncope</li>
</ul>
<div>
Pulmonary Embolism</div>
<div>
Aortic Dissection (thoracic)</div>
<br />
An Approach to Arrhythmias<br />
Infective Endocarditis<br />
<br />
<h4 style="text-align: left;">
Critical Care.</h4>
Sepsis<br />
<ul style="text-align: left;">
<li>SIRS, Sepsis & Septic Shock</li>
<li>Management of Septic Shock</li>
<li>Antibiotics in Sepsis</li>
</ul>
Inotropes<br />
<br />
<h4 style="text-align: left;">
Endocrinology/Metabolics</h4>
DKA Management<br />
Diabetic HHS<br />
Hypoglycaemia<br />
Hyperthyroidism + Thyroid Storm<br />
Hypothyroidism + Myxoedema Coma<br />
Adrenal Insufficiency<br />
Phaeochromocytoma<br />
Hyponatraemia<br />
Hypokalaemia / Hyperkalaemia<br />
Hypercalcaemia<br />
<br />
<h4 style="text-align: left;">
Gastroenterology</h4>
Upper GIT Bleeding<br />
<ul style="text-align: left;">
<li>Causes of Upper GIT bleeding</li>
<li>Clinical features mandating urgent endoscopy</li>
</ul>
Gastroentertitis<br />
<br />
<h4 style="text-align: left;">
General Surgery</h4>
Abdominal Aortic Anuersym<br />
Appendicitis<br />
<ul style="text-align: left;">
<li>Alvarado Score (Appendicitis)</li>
</ul>
Pancreatitis<br />
<ul style="text-align: left;">
<li>Ranson Criteria (Pancreatitis)</li>
</ul>
<div>
Intestinal Obstruction</div>
<div>
<br /></div>
<h4 style="text-align: left;">
Haematology</h4>
Transfusion Reactions<br />
Anaemias<br />
Thrombocytopenia<br />
DIC<br />
ITP & TTP<br />
<br />
<h4 style="text-align: left;">
Indigenous/ATSI</h4>
Acute Rheumatic Fever<br />
<br />
<br />
<h4 style="text-align: left;">
Infectious Diseases</h4>
HIV/AIDS<br />
Fever in a Returned Traveler<br />
<br />
<h4 style="text-align: left;">
Neurology/Neurosurgery</h4>
<a href="http://www.ivline.org/2018/06/rem-stroke-cerebrovascular-accident.html"><span style="color: #38761d;">Stroke</span></a> <span style="color: #38761d;">- current as of June 2018</span><br />
<span style="color: #38761d;"><a href="http://www.ivline.org/2018/07/rem-seizure-epilepsy.html">Seizure </a>- current as of July 2018</span><br />
<div>
<a href="http://www.ivline.org/2018/06/rem-acute-traumatic-brain-injury.html"><span style="color: #38761d;">Head Trauma</span></a> <span style="color: #38761d;">- current as of June 2018</span></div>
Subarachnoid Haemorrhage<br />
Meningitis<br />
Cerebral abscess<br />
Brainstem: Rule of 4’s<br />
<br />
<h4 style="text-align: left;">
Ophthalmology</h4>
Common Eye Complaints<br />
The Red Eye<br />
Angle Closure Glaucoma<br />
Ruptured Globe / Penetrating Eye Injury<br />
Aniscoria<br />
<br />
<h4 style="text-align: left;">
Orthopaedics</h4>
Elbow Xray<br />
Elbow Dislocation<br />
Shoulder Dislocations<br />
Shoulder Relocation Techniques<br />
Distal Radial Fractures (Colles, Smith & Barton)<br />
Forearm Fractures<br />
Scaphoid Fracture<br />
Scapholunate Dissociation<br />
Lunate & Perilunate Dislocations<br />
Ottawa Knee Rules<br />
Ottawa Ankle Rules<br />
Lower Leg Compartments<br />
Lower Leg Fractures<br />
<br />
<h4 style="text-align: left;">
Paediatrics</h4>
<a href="http://www.ivline.org/2018/08/rem-approach-to-seriously-ill-child.html">Approach the Seriously Ill Child </a>provides a structured approach to Paediatric Assessment.<br />
For more guidelines and the management of other conditions go to <a href="https://www.rch.org.au/clinicalguide/">Royal Children Hospital Clinical Guidelines</a> and do APLS.<br />
<br />
<h4 style="text-align: left;">
Psychiatric / Mental Health</h4>
Acute Psychosis/Agitated Patients<br />
Suicide Risk Assessment<br />
Depression<br />
Anxiety<br />
<br />
<h4 style="text-align: left;">
Renal + Electrolytes.</h4>
Causes of acute renal failure<br />
RIFLE criteria<br />
Indications for haemodialysis<br />
Sodium & Free-water correction<br />
Causes of rhabdomyolysis<br />
Hypotensive dialysis patient<br />
<br />
<h4 style="text-align: left;">
Toxicology</h4>
Approach to Toxicology<br />
<a href="http://www.ivline.org/2018/07/rem-snake-bite-envenomation.html">Snake Bite / Envenomation</a><br />
Osmolar Gap<br />
Anticholinergic Syndrome<br />
Cholinergic Crisis<br />
Neuroleptic Malignant Syndrome<br />
Serotonin Syndrome<br />
Dialysable Drugs<br />
<br />
<h4 style="text-align: left;">
Trauma</h4>
<a href="http://www.ivline.org/2012/04/ultimate-guide-to-trauma.html"><span style="color: #38761d;">Ultimate Guide to Trauma</span></a><span style="color: #38761d;"> - current as of June 2016</span><br />
Cervical Spine X-rays<br />
NEXUS Low-risk Criteria<br />
Canadian C-spine Rules<br />
Penetrating Neck Trauma (Hard & Soft Signs)<br />
<br />
<h4 style="text-align: left;">
Procedures</h4>
Rapid Sequence Intubation<br />
Lumbar puncture<br />
Chest Drain insertion<br />
Central Venous Line insertion<br />
Procedural Sedation<br />
Biers Block<br />
<br /></div>
Aaron Sparshotthttp://www.blogger.com/profile/16868086818074290497noreply@blogger.com0tag:blogger.com,1999:blog-4281944981424326587.post-4209000512745109952017-12-09T15:17:00.001+10:002018-05-28T00:09:44.521+10:00Optimising Local Anaesthetic Administration<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgtZZF1EnoSDtKUT1IGRNOy1SEcTIzQzBVds1rLujFdjMOg5pH25VJFLBa4hfcAslzf2E2VC4cZLkx69xpw329WlAxdwz7M8GtIcGLfTz2yIgmZOLnIazSlOOuF9XhJWA7IamzU7HYEgWSU/s1600/LA-bigneedle.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="650" data-original-width="959" height="216" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgtZZF1EnoSDtKUT1IGRNOy1SEcTIzQzBVds1rLujFdjMOg5pH25VJFLBa4hfcAslzf2E2VC4cZLkx69xpw329WlAxdwz7M8GtIcGLfTz2yIgmZOLnIazSlOOuF9XhJWA7IamzU7HYEgWSU/s320/LA-bigneedle.png" width="320" /></a></div>
<br />
Providing adequate analgesia to patients prior to performing procedures is not only beneficial to patient, but also aids the clinician. Importantly, the patient's experience of the entire process will often determine how happy they feel about the eventual outcome. Often the most painful part of the procedure in community and emergency department settings will be the infiltration of the local anaesthetic.<br />
<br />
With infiltrating local anaesthetic there are a number of tips, tricks and steps that you can take to simplify the process and minimise the pain. I have sourced this advice from my fellow clinicians, the literature and across the web. If you have any tips please feel free to share them in the comments section below. This is an adjunct post to the <a href="http://www.ivline.org/2017/08/basic-guide-to-suturing.html">Basic Guide to Suturing Series</a>.<br />
<br />
So here is the quick users guide to reducing the pain of and improving your local anaesthetic administration.<br />
<br />
<h3 style="text-align: left;">
Dose Correctly</h3>
Getting the right dose either using the traditional calculations or this handy little dosing nomogram - <a href="http://www.aliem.com/pv-card-local-anesthetic-toxicity-calculations/">http://www.aliem.com/pv-card-local-anesthetic-toxicity-calculations/</a> <br />
And from the literature <a href="http://onlinelibrary.wiley.com/doi/10.1111/anae.12679/full">http://onlinelibrary.wiley.com/doi/10.1111/anae.12679/full </a><br />
<br />
IBW Calculator - <a href="http://www.mdcalc.com/ideal-body-weight/#about-calculator">http://www.mdcalc.com/ideal-body-weight/#about-calculator</a><br />
<br />
<table border="1" cellpadding="2" cellspacing="2"><tbody>
<tr><td valign="top" width="125"><br /></td>
<td valign="top" width="75">Onset (min)</td>
<td valign="top" width="75">Duration (min)</td>
<td valign="top" width="125">Max dose (mg/kg)</td>
<td valign="top" width="125">Max mg (70kg person)</td>
</tr>
<tr style="text-align: center;">
<td valign="top" width="125">Lignocaine (1% or 2%)<br />
(Xylocaine)</td>
<td valign="top" width="75">2</td>
<td valign="top" width="75">15-60</td>
<td valign="top" width="125">3mg/kg</td>
<td valign="top" width="125">220mg<br />
(11mL 2%)<br />
(22mL 1%)</td>
</tr>
<tr style="text-align: center;">
<td valign="top" width="125">Lignocaine with adrenaline<br />
(1% or 2%)</td>
<td valign="top" width="75">2</td>
<td valign="top" width="75">120-360</td>
<td valign="top" width="125">7mg/kg</td>
<td valign="top" width="125">500mg<br />
(25mL 2%)<br />
(50mL 1%)</td>
</tr>
<tr style="text-align: center;">
<td valign="top" width="125">Bupivicaine (0.25%)<br />
(Marcain)</td>
<td valign="top" width="75">5</td>
<td valign="top" width="75">120-240</td>
<td valign="top" width="125">2.5mg/kg</td>
<td valign="top" width="125">175mg(50mL)</td>
</tr>
<tr style="text-align: center;">
<td valign="top" width="125">Bupivicaine with adrenaline</td>
<td valign="top" width="75">5</td>
<td valign="top" width="75">180-420</td>
<td valign="top" width="125">3mg/kg</td>
<td valign="top" width="125">225mg</td>
</tr>
<tr style="text-align: center;">
<td valign="top" width="125">Prilocaine (0.5% or 1%)<br />
(Citanest)</td>
<td valign="top" width="75">2</td>
<td valign="top" width="75">30-90</td>
<td valign="top" width="125">7mg/kg</td>
<td valign="top" width="125">500mg<70kg 1="" ml="" td="">
</70kg></td></tr>
<tr style="text-align: center;">
<td valign="top" width="125">Ropivocaine (0.25%)<br />
(Naropin)</td>
<td valign="top" width="75">5</td>
<td valign="top" width="75">120-360</td>
<td valign="top" width="125">3mg/kg</td>
<td valign="top" width="125">225mg</td></tr>
</tbody></table>
<div style="text-align: left;">
<br /></div>
<h3 style="text-align: left;">
Solution preparation for minimal pain</h3>
<ul style="text-align: left;">
<li>Appropriate dosing</li>
<li>Buffer with sodium bicarbonate(e.g. 1mL of 8.4% sodium bicarbonate to 9 mL of 1% lignocaine.)</li>
<li>Warm the LA</li>
</ul>
<br />
<h3 style="text-align: left;">
Equipment </h3>
<ul style="text-align: left;">
<li>Smallest needle</li>
<li>Longer needle: requiring fewer injection points to cover the same area</li>
<li>Consider using a diabetic needle for first infiltration</li>
<li>Use fresh needles (i.e. sharper needles)</li>
<li>Appropriate syringe size (less pressure, and less likely to overdose)</li>
</ul>
<br />
<h3 style="text-align: left;">
Patient preparation </h3>
<ul style="text-align: left;">
<li>Look away</li>
<li>Distraction (e.g. smartphones, music, tv)</li>
<li>Gentle pinching or vibration adjacent to the site of injection</li>
</ul>
<br />
<h3 style="text-align: left;">
Paediatric Population</h3>
<ul style="text-align: left;">
<li>Use 1% for paeds patients.</li>
<li>Play specialist</li>
<li>Topical Analgesia</li>
<li>- ALA (Laceraine): a combination of 0.5% amethocaine, 4% lignocaine and 0.1% adrenaline</li>
<li>- EMLA is non-sterile and not approved for application to broken skin</li>
<li>Consider other options; e.g. gas, procedural sedation etc.</li>
</ul>
<br />
Further reading;<br />
<ul style="text-align: left;">
<li><a href="http://www.rcemfoamed.co.uk/portfolio/paediatric-wound-management/">RCEM: Paediatric Wound Management</a></li>
<li><a href="http://lifeinthefastlane.com/kids-cuts-and-clinical-care/">LITFL: Kids, Cuts and Clinical Care</a></li>
</ul>
<div>
<br /></div>
<h3 style="text-align: left;">
Procedural</h3>
<ul style="text-align: left;">
<li>Topical Anaesthetic</li>
<li>Inject into Subcutaneous Fat if There Is an Open Wound</li>
<li>Infiltrate through wound edges, rather than unbroken skin (clean wound)</li>
<li>Stabilise the Syringe Holding Hand to Minimise Needle Movement</li>
<li>Inject Very Slowly</li>
<li>Keep the Local Anaesthetic Wheal 10 mm ahead of the Needle Tip</li>
<li>Decrease number of insertions</li>
<li>Use smallest volume necessary</li>
</ul>
<br />
<h3 style="text-align: left;">
Get feedback from your patients</h3>
<div style="text-align: left;">
<ul style="text-align: left;">
<li>Getting feedback from your patients can help learn what works and what does not when administering local anaesthetic, to give the patient the most ideal experience.</li>
</ul>
<br /><ul style="text-align: left;">
</ul>
</div>
<h3 style="text-align: left;">
References/Further Reading</h3>
<ul style="text-align: left;">
<li>http://www.ncbi.nlm.nih.gov/pubmed/17499653 </li>
<li>http://www.mdedge.com/cutis/article/100528/practice-management/minimize-pinch-and-burn-tips-and-tricks-reduce-injection</li>
</ul>
</div>
Aaron Sparshotthttp://www.blogger.com/profile/16868086818074290497noreply@blogger.com0tag:blogger.com,1999:blog-4281944981424326587.post-17760015772266643372017-09-11T11:06:00.002+10:002018-05-28T00:27:22.214+10:00Introduction to Sexual Health<div dir="ltr" style="text-align: left;" trbidi="on">
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<br />
Sexual Health goes beyond just the mechanical motions of sexual intercourse, and encompasses much more, including but not limited too; relationships, gender identity, contraception and pregnancy, infectious diseases and sexual assault.<br />
<br />
This post provides just a brief introduction to the world of Sexual Health, particularly looking at Sexually Transmitted Infections (STIs)/Diseases and Blood Borne Viruses (BBVs).<br />
<br />
<h3>
Key Resources</h3>
Rather than my traditional way of keeping the goodies to till the end, I have provided some key open access resources specific to STIs which I think should not be overlooked.<br />
<dl style="text-align: left;">
<dd>- <a href="http://www.ivline.org/2017/09/sti-tool-guide-to-testing-stis.html">STI Tool </a></dd>
<dd>- <a href="http://www.ivline.org/2017/09/sti-atlas-photo-library.html">STI Atlas</a></dd>
<dd>- <a aiotarget="false" aiotitle="STI Guidelines" href="http://www.ivline.org/2017/09/sti-management-guidelines-for-primary.html">Australian STI Management Guidelines</a></dd>
</dl>
<br />
<h3 style="text-align: left;">
Approach</h3>
The NSW STI Programs unit has put a nice simple approach together for clinicians to follow in STI assessment and management.<br />
<ol style="text-align: left;">
<li><b>Start the conversation about Sexual Health.</b>- Consider approach language for that demographic<br />- Ensure a safe environment<br />- History and assess risk factors<br />- Examination as appropriate</li>
<li><b>What and how to test your patients.</b>- Testing based off earlier assessment and population groups<br />- Consider most appropriate method of testing (e.g. swab, urine, blood test)<br />- Opportunistic testing (e.g. doing a high vaginal swab, whilst doing a Pap Smear)</li>
<li><b>Contact Tracing</b>- Prevent re-infection for your patient and the onward transmission of the disease.<br />- Understand the timeframes for specific STIs<br />- Using the appropriate resources to contact trace and inform third parties</li>
</ol>
<div>
NSW STI Programs unit's four page quick cheat sheet is <a href="https://stipu.nsw.gov.au/wp-content/uploads/STI-HIV-Testing-Tool-online.pdf">available here</a>.<br />
<br /></div>
<h3 style="text-align: left;">
Rules of Sexual Health</h3>
<ol style="text-align: left;">
<li>Assume nothing. </li>
<li>All STIs can produce disease without causing symptoms.</li>
<li>More than one STI or BBV can be present</li>
<li>Do not presume that the presenting genital problem is the only problem.</li>
<li>Respect difference.</li>
</ol>
<div>
<br /></div>
<h3 style="text-align: left;">
Sexual Health History</h3>
The importance of communication and language can and should never be down played in consulting, however it is particular important in Sexual Health. The correct use of language can make; people feel comfortable opening up to you on topics that might be very personal to them, feel validated and that you understand them as a person and their associated identity, help them risk mitigate and manage their own condition moving forward. Clarifying the language the patient uses regarding genitals and what sexual intercourse means to them is also important step.<br />
<br />
<blockquote class="tr_bq">
<span style="color: #666666;">For example in Men who have Sex with Men (MSM) in regards to anal sex, you may want to find out who is penetrating and who is receiving. These terms may for them personally, and it will sometimes require more simple or vulgar language -> “Did you fu*k him in the butt or did he fu*k you?”</span></blockquote>
<br />
Below are some areas to get you started and think about. I am however, not expert in this area so I've included a link to the Australian STI Guidelines take on <a href="http://www.sti.guidelines.org.au/resources/how-to-take-a-sexual-history#how-to-take-a-sexual-history">Sexual History Taking</a>.<br />
<br />
<ul style="text-align: left;">
<li>Regular Partners</li>
<li>Other Partners</li>
<li>Nature of Sexual Contact</li>
<li>Condom Use</li>
<li>Past history of STI</li>
<li>Overseas Contact</li>
<li>Sexual function difficulties</li>
<li>What age did the patient first experience sexual contact</li>
<li>Of course for all females; are you or is there a possibility you could be pregnant.</li>
</ul>
<br />
<br />
Aside from taking a more focussed Sexual Health History, you still need to cover your standard Past Medical History, Allergies, Medications, Social History and so on.<br />
<br />
I have always like the <a href="http://contemporarypediatrics.modernmedicine.com/contemporary-pediatrics/content/tags/adolescent-medicine/heeadsss-30-psychosocial-interview-adolesce?page=full">HEEADSSS psychosocial interview </a>and despite being designed for adolescents I think it can be often used and adapted if required for any age of life. In the context of sexual health, I think that it can a useful tool to assess factors that may positively or negatively influence their sexual health. In addition, guide appropriate testing and management strategies that are more applicable to that individual.<br />
<br />
<dl style="text-align: left;">
<dd><b>H </b>– Home </dd>
<dd><b>E</b> – Education & Employment </dd>
<dd><b>E</b> – Eating & Exercise </dd>
<dd><b>A</b> – Activities & Peer Relationships </dd>
<dd><b>D</b> – Drug Use/Cigarettes/Alcohol </dd>
<dd><b>S</b> – Sexuality </dd>
<dd><b>S</b> – Suicide and Depression
(including mood &possible psychiatric symptoms) </dd>
<dd><b>S </b>– Safety (also Spirituality)</dd><br />
</dl>
<div>
If you are really floundering in what to ask for in a Sexual Health History or just like something short and snappy to remember than think of The 5 P's for Sexual History.<br />
<div style="text-align: left;">
</div>
<dl style="text-align: left;">
<dd><b>P</b> artners </dd>
<dd><b>P</b> revention of Pregnancy </dd>
<dd><b>P</b> rotection from STDs </dd>
<dd><b>P</b> ractices </dd>
<dd><b>P</b> ast History of STDs</dd>
</dl>
<div>
<br />
The CDC has developed this <a href="https://www.cdc.gov/std/treatment/sexualhistory.pdf">little handout</a> that goes in to the 5 P's a little more.<br />
<br /></div>
</div>
<div>
<br /></div>
<h3 style="text-align: left;">
Common Sexual Health Diseases</h3>
<div>
Prevalence of the various STIs is dependant upon the region in which you live and work. However, there are a number that are fairly common globally which I will cover below.<br />
<br />
Like most things in life, be aware of what is going around in your local patch, and the strategies that are used locally.<br />
<div class="separator" style="clear: both; text-align: center;">
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<div class="separator" style="clear: both; text-align: center;">
<br /></div>
</div>
<div>
<div class="separator" style="clear: both; text-align: left;">
The <a href="http://ww2.health.wa.gov.au/~/media/Files/Corporate/Reports%20and%20publications/Silverbook/quick-reference-to-sti-management.ashx">Quick Guide to STI Management </a>from Western Australian Department of Health covers nearly all the common sexual health diseases. Remember to check your local guidelines as well, however this is short and succinct document if all else fails.</div>
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="http://www.sti.guidelines.org.au/sexually-transmissible-infections/chlamydia"><img border="0" data-original-height="150" data-original-width="600" src="https://1.bp.blogspot.com/-urlJEx_xQ-Y/Wapq9CkyCmI/AAAAAAAADFU/sjuF_9ykUAAYdBcQdB3TBY8IfPpmWKhEwCLcBGAs/s1600/Chlamydia.png" /></a></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="http://www.sti.guidelines.org.au/sexually-transmissible-infections/herpes"><img border="0" data-original-height="150" data-original-width="600" src="https://3.bp.blogspot.com/-5nRAjQFTTBg/Wapq-aXK8cI/AAAAAAAADFg/dXbDuyFhOjIFQDi7wnJ6IFWCBU1eADyPgCLcBGAs/s1600/Herpes.png" /></a></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="http://www.sti.guidelines.org.au/sexually-transmissible-infections/trichomoniasis"><img border="0" data-original-height="150" data-original-width="600" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgfADJtgTIdbErKsbWL1uzcQjpc3NdZ-Rx9ds7RZIyL601JDMgM_PC963vPwBDIKt28HvdBWtUEy09MRv1e5C0WWAOkblToIRSbuPJbEml5WTic95BZydOxMhyphenhyphenclejV75iHTL8WQRDMFvtg/s1600/Trichomonas.png" /></a></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="http://www.sti.guidelines.org.au/sexually-transmissible-infections/syphilis"><img border="0" data-original-height="150" data-original-width="600" src="https://2.bp.blogspot.com/-vDVJwJb9Xxs/Wapq-5dIA5I/AAAAAAAADFk/fEVS3dgJefcgg4CiWLG06H8E3uHKaDRpwCEwYBhgL/s1600/Syphillis.png" /></a></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="http://www.sti.guidelines.org.au/sexually-transmissible-infections/gonorrhoea"><img border="0" data-original-height="150" data-original-width="600" src="https://3.bp.blogspot.com/-fWx8DZd0lig/Wapq8296HPI/AAAAAAAADFQ/5buuEM1wLEQS8NKnK76yo52SN7RUmhRywCEwYBhgL/s1600/Gonorrhoea.png" /></a></div>
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<div class="separator" style="clear: both; text-align: center;">
<a href="http://www.sti.guidelines.org.au/sexually-transmissible-infections/hepatitis-b"><img border="0" data-original-height="150" data-original-width="600" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg6acaq1_YKnVhKJyVCeAcX78n1WdAFhxnqUKOQdpYliqpAmOL9_bw2FWokQuoR4P-6watVPYFq5VQqpscR2v1d6OFXB-9yuTKjrcXDa-1AmR0iwkaCFsxS8qbq5YJ9TL8W4tIMwPGSfYwK/s1600/Hepatitis+B.png" /></a></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="http://www.sti.guidelines.org.au/sexually-transmissible-infections/infections-associated-with-sex/hepatitis-c"><img border="0" data-original-height="200" data-original-width="600" src="https://2.bp.blogspot.com/-A0iDm2_eyP0/Wapq-MImsqI/AAAAAAAADFc/cYOmbMfUKVgHKkwELBTwE-TDwxSpADEHQCEwYBhgL/s1600/Hepatitis%2BC.png" /></a></div>
<br /></div>
<h3 style="text-align: left;">
Asymptomatic Testing</h3>
Tests for all sexually active people.<br />
<ul style="text-align: left;">
<li>Chlamydia (males): FPU - NAAT</li>
<li>Chlamydia (females): Endocervical swab – NAAT , Self-collected vaginal swab – NAAT , FPU – NAAT, Ano-rectal swab </li>
</ul>
<br />
Consider the following tests for individuals who are not from a high risk population group. To determine risk, take a sexual history.<br />
<ul style="text-align: left;">
<li>Hepatitis B: Blood – HBsAg, Anti-HBs, Anti-HBc </li>
<li>HIV: Blood – HIV Ag/Ab </li>
<li>Syphilis: Blood – Syphilis serology </li>
</ul>
<br />
Additional test to consider in asymptomatic individuals;<br />
<ul style="text-align: left;">
<li>Gonorrhoea: NAAT and/or Culture</li>
</ul>
<div>
<br /></div>
<div>
Also give the <a href="http://www.mshc.org.au/Portals/0/Documents/HealthProfessional/STITool/stiTool1.7.pdf">STI Tool</a> a go to help determine what test you might need.<br />
<br /></div>
<h3 style="text-align: left;">
Population Groups</h3>
<div>
For more details regarding Sexual Health assessment in particular population groups<br />
click below;<br />
<dl style="text-align: left;">
<ul style="text-align: left;"><dd><a href="http://www.sti.guidelines.org.au/populations-and-situations/aboriginal-and-torres-strait-islander">Aboriginal and Torres Strait Islander people </a></dd><dd><a href="http://www.sti.guidelines.org.au/populations-and-situations/adult-sexual-assault">Adult Sexual Assault </a></dd><dd><a href="http://www.sti.guidelines.org.au/populations-and-situations/msm">MSM - Men who have sex with men </a></dd><dd><a href="http://www.sti.guidelines.org.au/populations-and-situations/people-in-correctional-facilities">People in correctional facilities </a></dd><dd><a href="http://www.sti.guidelines.org.au/populations-and-situations/plwhiv-people-living-with-hiv">PLWHIV - People Living with HIV </a></dd><dd><a href="http://www.sti.guidelines.org.au/populations-and-situations/pregnant-women">Pregnant Women </a></dd><dd><a href="http://www.sti.guidelines.org.au/populations-and-situations/pwid-people-who-inject-drugs">PWID - People who inject drugs </a></dd><dd><a href="http://www.sti.guidelines.org.au/populations-and-situations/refugees-including-migrants-from-similar-settings">Refugees (and newly arrived migrants from similar settings) </a></dd><dd><a href="http://www.sti.guidelines.org.au/populations-and-situations/rural-remote">Regional/Remote </a></dd><dd><a href="http://www.sti.guidelines.org.au/populations-and-situations/sex-workers">Sex workers </a></dd><dd><a href="http://www.sti.guidelines.org.au/populations-and-situations/transgender">Transgender</a> </dd><dd><a href="http://www.sti.guidelines.org.au/populations-and-situations/wsw-women-who-have-sex-with-women">WSW - Women who have sex with women </a></dd><dd><a href="http://www.sti.guidelines.org.au/populations-and-situations/young-people">Young people</a></dd></ul>
</dl>
<div>
<br /></div>
</div>
<h3 style="text-align: left;">
</h3>
<h3 style="text-align: left;">
A Career in Sexual Health</h3>
Interested in a Career in Sexual Health Medicine in Australia? See the <a href="https://www.racp.edu.au/trainees/advanced-training/advanced-training-programs/sexual-health-medicine">Royal Australasian College of Physicians</a> for more details about how to expand your skills in this area. <br />
This <a href="https://www.racp.edu.au/docs/default-source/default-document-library/achshm-careers-flyer.pdf?sfvrsn=2">flyer</a> provides a brief overview of the program.<br />
<br />
<h3 style="text-align: left;">
References and Resources</h3>
<ol style="text-align: left;">
<li>The 5 P's for Sexual Behaviour History Taking: https://aidsetc.org/resource/5-ps-sexual-behavior-history-taking</li>
<li>STI Tool: <a href="http://www.mshc.org.au/Portals/0/Documents/HealthProfessional/STITool/stiTool1.7.pdf">http://www.mshc.org.au/Portals/0/Documents/HealthProfessional/STITool/stiTool1.7.pdf</a></li>
<li>STI Atlas: <a href="http://stiatlas.org/SearchAtlas.aspx">http://stiatlas.org/SearchAtlas.aspx</a></li>
<li>STI Guidelines: <a href="http://www.sti.guidelines.org.au/">http://www.sti.guidelines.org.au/</a></li>
<li>ReachOut.com: <a href="https://au.reachout.com/relationships">https://au.reachout.com/relationships</a></li>
<li>CDC - A Guide to Taking a Sexual History: <a href="https://www.cdc.gov/std/treatment/sexualhistory.pdf">https://www.cdc.gov/std/treatment/sexualhistory.pdf</a></li>
<li>NSW STI/HIV Testing Tool: <a href="https://stipu.nsw.gov.au/wp-content/uploads/STI-HIV-Testing-Tool-online.pdf">https://stipu.nsw.gov.au/wp-content/uploads/STI-HIV-Testing-Tool-online.pdf </a></li>
<li>Western Australian Department of Health - SilverBook Guidelines for managing sexually transmitted infections and blood-borne viruses: <a href="http://ww2.health.wa.gov.au/Silver-book">http://ww2.health.wa.gov.au/Silver-book </a></li>
</ol>
<br />
<br /></div>
Aaron Sparshotthttp://www.blogger.com/profile/16868086818074290497noreply@blogger.com0tag:blogger.com,1999:blog-4281944981424326587.post-48745372178309479432017-09-03T01:22:00.000+10:002018-05-28T00:21:54.816+10:00Local Anaesthetic for Wound Management<div dir="ltr" style="text-align: left;" trbidi="on">
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<div class="separator" style="clear: both; text-align: center;">
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<br />
This post is part of the <a href="http://www.ivline.org/2017/08/basic-guide-to-suturing.html">Basic Guide to Suturing</a> series. Here we take a look at using local anaesthetic, to help us manage a simple wound/laceration. <br />
<br />
Firstly a recap of the wound management process. <br />
<ol style="text-align: left;">
<li><a href="http://www.ivline.org/2017/08/preparation-wound-management-principles.html">Assess</a></li>
<li><a href="http://www.ivline.org/2017/08/preparation-wound-management-principles.html">Gather required equipment</a></li>
<li><a href="http://www.ivline.org/2017/08/preparation-wound-management-principles.html">Prep & Drape</a></li>
<li>Anaesthetise</li>
<li>Clean/Irrigate</li>
<li>Suture (see Overview of Suturing Techniques for more details)</li>
<li>Bandaging/Dressing and ongoing wound-care</li>
</ol>
<ol style="text-align: left;">
</ol>
<div style="text-align: left;">
Remember if cleaning the wound is painful or difficulty to examine, anaesthetising earlier may be beneficial and kinder to your patient. <br />
<br />
<h3 style="text-align: left;">
Indications</h3>
<div>
<ul style="text-align: left;">
<li>For pain control and analgesia during a procedure or assessment</li>
</ul>
</div>
</div>
<h3 style="text-align: left;">
Contraindications</h3>
<div>
<div>
<ul style="text-align: left;">
<li>Known allergic reaction or anaphylaxis</li>
<li>Large or multiple lacerations requiring significant doses</li>
<li>Local tissue infection (relative)</li>
<li>Patient refusal</li>
</ul>
</div>
<div>
<br /></div>
</div>
</div>
<div style="text-align: left;">
<h3 style="text-align: left;">
Precautions</h3>
</div>
<div>
<ul style="text-align: left;">
<li>Intravascular injection of local anaesthetic (injection should follow Aspiration to ensure extravascular administration)</li>
<li>Use of adrenaline (see below for areas and particular patients where caution should be used)</li>
<li>Prior adverse reaction (including vasovagal reaction)</li>
<li>Pre-existing neurological and cardiac disorders</li>
<li>Hepatic or renal impairment</li>
</ul>
</div>
<div>
<br /></div>
<h3 style="text-align: left;">
A bit about Local Anaesthetics </h3>
<blockquote class="tr_bq">
<blockquote class="tr_bq">
“<span style="color: #444444;">A local anaesthetic can be defined as a drug which reversibly prevents transmission of the nerve impulse in the region to which it is applied, without affecting consciousness.</span>” FRCA </blockquote>
</blockquote>
<br />
It is important as a Medical Student or Junior Doctor to have a basic understanding of the side-effects, doses and key properties of common local anaesthetics. In general, local anaesthetics work by stabilising the neuronal membrane and preventing the transmission of nerve impulses.<br />
<br />
An overview of Lignocaine is provided here. For other agents, see the comparison table below.<br />
For more details see <a href="http://www.icuadelaide.com.au/files/primary/pharmacology/local_anaesthetics.pdf">Local Anaesthetics</a> by the Royal Adelaide ICU, useful resource for those studying for the various critical care primary examinations.<br />
<br />
<h3 style="text-align: left;">
<span style="font-weight: normal;">Lignocaine/Lidocaine/Xylocaine </span></h3>
Lignocaine is one of the most commonly used local anaesthetic agents. It is suitable for surface, infiltration, nerve block, caudal, epidural, and spinal anaesthesia.<br />
<br />
<b>MOA </b><br />
<ul style="text-align: left;">
<li>Binds selectively to refractory Na+ channels -> preferentially when cells are depolarised</li>
</ul>
<b>Dosing</b><br />
<ul style="text-align: left;">
<li>Maximum dose of lignocaine without adrenaline is ~3 mg/kg.</li>
<li>Maximum dose of lignocaine with adrenaline is ~7 mg/kg. </li>
</ul>
<b>Adverse effects</b><br />
<ul style="text-align: left;">
<li>lightheadedness</li>
<li>hypotension</li>
<li>cardiovascular collapse</li>
<li>heart block</li>
<li>confusions</li>
<li>seizures</li>
</ul>
<br />
<h3 style="text-align: left;">
<span style="font-weight: normal;">Adrenaline/Epinephrine </span></h3>
Adrenaline is a common additive in your local anaesthetic. Acting as a vasoconstrictor, it helps prolong the action of your local anaesthetic, decrease systemic absorption and risk of toxicity, and reduce traumatic blood loss. Consequently, it also allows you to deliver a higher dose of your local anaesthetic.<br />
<br />
<b>Contraindications</b><br />
<ul style="text-align: left;">
<li>Conditions where tachycardia is detrimental (thyrotoxicosis, CCF, IHD)</li>
<li>Periorbital infiltration in patients with narrow angle glaucoma</li>
<li>Digital anaesthesia in patients with peripheral artery disease </li>
</ul>
<b>Precautions </b><br />
<ul style="text-align: left;">
<li>Patients with catecholamine sensitivity</li>
<li>Patients taking monoamine oxidase inhibitors, beta blockers, anti-arrhythmics, phenothiazines, or tricyclic antidepressants</li>
<li>Pregnant patients</li>
</ul>
<br />
<h3 style="text-align: left;">
Equipment</h3>
<div>
<div>
<ul style="text-align: left;">
<li>Local Anaesthetic Agent</li>
<li>Syringe (e.g. 5ml, 10ml)</li>
<li>Needles (large sharp or blunt drawing up needle; 25-30G needle for infiltration)</li>
<li>Personal protective equipment</li>
<li>Skin cleansing agent (e.g. alcohol swabs/wipes, chlorhexidine or povidone-iodine solution)</li>
<li>Sterile Gauze</li>
</ul>
</div>
</div>
<div>
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<br />
<h3 style="text-align: left;">
Dosing</h3>
<div>
Be aware of the parameters of the Local Anaesthetic you are using and it's safety profile.<br />
<div>
See the table below for common local anaesthetic agents. More details on how to accurately dose local anaesthetics in <a href="http://www.ivline.org/2017/12/optimising-local-anaesthetic.html">Optimising Local Anaesthetic Administration</a>.<br />
<br /></div>
</div>
<h3 style="text-align: left;">
Procedure (local infiltration) </h3>
<ol style="text-align: left;">
<li>Discuss with and gain patient consent for the procedure. </li>
<li>Consider use of topical analgesics, as they will take some time to work. </li>
<li>Gather required equipment and don PPE. </li>
<li>Draw up your local anaesthetic by either sharp or blunt needle, or directly via syringe from the ampule. </li>
<li>Prepare skin with cleansing agent (chlorhexidine or povidone-iodine) if infiltrating through intact skin. Allow skin to air-dry or dry with your sterile gauze. </li>
<li>Remove any gross contamination inside the wound with normal saline. </li>
<li>Then insert the needle directly though the wound edge (rather than intact skin where possible) into the subcutaneous layer. </li>
<li>Aspirate to rule out intravascular placement. </li>
<li>Advance needle forward and slowly inject small volumes of LA. Alternatively advance needle the full distance and inject slowly on withdrawal.</li>
<li>Remove needle. </li>
<li>Repeat until the area is fully anaesthetised or maximum dose is reached. Re-insert the needle if required through previously anaesthetised areas. </li>
<li>Wait for the anaesthetic to take effect, and then test for adequate coverage. Use either your injection needle or other sharp object (e.g. suture needle) to test anaesthetic coverage. </li>
<li>You are now free to further examine, clean/irrigate the wound or begin your primary procedure (e.g. suturing). </li>
</ol>
<br />
<ol style="text-align: left;">
</ol>
<h3 style="text-align: left;">
Post-Procedure Care </h3>
Patients should be advised of likely timeframes for recovery of full sensation after Local Anaesthetic administration. Consequently, it is also important to assess neurovascular status prior to injecting local anaesthetic.<br />
<br />
They should also lookout for/represent if;<br />
<ul style="text-align: left;">
<li>infection or neurovascular compromise</li>
<li>systemic toxicity</li>
<li>allergic reaction</li>
</ul>
<br />
<h3 style="text-align: left;">
Optimising local administration</h3>
See <a href="http://www.ivline.org/2017/12/optimising-local-anaesthetic.html">Optimising Local Anaesthetic Administration</a> for handy tip/tricks. <br />
<br />
<h3 style="text-align: left;">
Local Anaesthetic Table</h3>
<table border="1" cellpadding="2" cellspacing="2"><tbody>
<tr><td valign="top" width="125"><br /></td>
<td valign="top" width="75">Onset (min)</td>
<td valign="top" width="75">Duration (min)</td>
<td valign="top" width="125">Max dose (mg/kg)</td>
<td valign="top" width="125">Max mg (70kg person)</td>
</tr>
<tr style="text-align: center;">
<td valign="top" width="125">Lignocaine (1% or 2%)<br />
(Xylocaine)</td>
<td valign="top" width="75">2</td>
<td valign="top" width="75">15-60</td>
<td valign="top" width="125">3mg/kg</td>
<td valign="top" width="125">220mg<br />
(11mL 2%)<br />
(22mL 1%)</td>
</tr>
<tr style="text-align: center;">
<td valign="top" width="125">Lignocaine with adrenaline<br />
(1% or 2%)</td>
<td valign="top" width="75">2</td>
<td valign="top" width="75">120-360</td>
<td valign="top" width="125">7mg/kg</td>
<td valign="top" width="125">500mg<br />
(25mL 2%)<br />
(50mL 1%)</td>
</tr>
<tr style="text-align: center;">
<td valign="top" width="125">Bupivicaine (0.25%)<br />
(Marcain)</td>
<td valign="top" width="75">5</td>
<td valign="top" width="75">120-240</td>
<td valign="top" width="125">2.5mg/kg</td>
<td valign="top" width="125">175mg(50mL)</td>
</tr>
<tr style="text-align: center;">
<td valign="top" width="125">Bupivicaine with adrenaline</td>
<td valign="top" width="75">5</td>
<td valign="top" width="75">180-420</td>
<td valign="top" width="125">3mg/kg</td>
<td valign="top" width="125">225mg</td>
</tr>
<tr style="text-align: center;">
<td valign="top" width="125">Prilocaine (0.5% or 1%)<br />
(Citanest)</td>
<td valign="top" width="75">2</td>
<td valign="top" width="75">30-90</td>
<td valign="top" width="125">7mg/kg</td>
<td valign="top" width="125">500mg<70kg 1="" ml="" td="">
</70kg></td></tr>
<tr style="text-align: center;">
<td valign="top" width="125">Ropivocaine (0.25%)<br />
(Naropin)</td>
<td valign="top" width="75">5</td>
<td valign="top" width="75">120-360</td>
<td valign="top" width="125">3mg/kg</td>
<td valign="top" width="125">225mg</td></tr>
</tbody></table>
<br />
<h3 style="text-align: left;">
Alternatives</h3>
Nitrous oxide (Entonox®), topical analgesia, sedation, general anaesthesia <br />
<br />
<h3 style="text-align: left;">
Local Anaesthetic Toxicity</h3>
<br />
<ul style="text-align: left;">
<li>LITFL: <a href="https://lifeinthefastlane.com/tox-library/toxicant/anaesthetics/local-anaesthetic/">Guide to Local Anaesthetic Toxicity</a></li>
<li>LITFL: <a href="https://lifeinthefastlane.com/ccc/local-anaesthetic-toxicity/">CCC Local Anaesthetic Toxicity</a></li>
</ul>
<br />
<br />
<h3 style="text-align: left;">
References:</h3>
<br />
<ul style="text-align: left;">
<li>LITFL: Lignocaine</li>
<li>Essentials of Local Anesthetic Pharmacology (2006)</li>
</ul>
</div>
</div>
Aaron Sparshotthttp://www.blogger.com/profile/16868086818074290497noreply@blogger.com0