ED Rounds – EM Teaching Techniques – Dr James French

EM Teaching Techniques

Presented by Dr James French


Read the RSI Drugs Summary first – LINK

1. We are going to have a flipped classroom discussion about RSI drug doses. Flipped classroom sessions require you do a little work beforehand. Please find attached a brief summary of RSI drug doses and a podcast with slides to use. It wont take long. http://sjrhem.ca/sjrhem-podcast-rsi-drugs-basics/

2. We are going to do a deliberate practice session using micro skills on laryngoscopy (which should be fun) to illustrate how microskills and deliberate practice works…..

3. We will then have a discussion around performance and behaviour as a stand alone competence….

4. And then how this all ties into simulation….


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ED Rounds – EM and Hand Surgery – Dr Don Lalonde

EM and Hand Surgery

Presented by Dr. Don Lalonde

An excellent double presentation by Dr Don Lalonde, who wanted to start his presentation by thanking the ED staff (Physicians and Nurses) for all their help over the last few years. A selection of relevant papers from his numerous publications are included at the end of this report.


 Digital Block

“Wide awake local anaesthetic no tourniquet”

Epinephrine in the finger is safe (see references attached below)
Phentolamine reversal – starts at 5mins completely reverse at an 1hr (dose is 1mg). Although rarely required.
Cause of the myth – (born before 1950) – Procaine was responsible (ph 3.6 – became more acidic on shelf – down to 1.0)


Single subcut
Prox Phal
In the fat not in flexor sheath
Don’t stick needle in nerve. Near nerve not in it….
Use 27 needle or 30G
Use 2cc syringe
60sec less painful than 2sec – therefore go slow
Push skin into needle rather than vice versa (sensory noise)
Get through dermis
But doesn’t get dorsum of finger
So 2nd needle injection required
Lidocaine with Epinephrine = 10hrs
Lidocaine without Epinephrine = 5hrs
Bupivicaine – pain returns at 15hrs, pressure touch 30hrs
But not cardiac friendly
Can rescue with Intralipid

Median nerve Block

10ml better than 5ml
But takes 1 hr to get finger numb
Wait a minimum of 40mins
Therefore tumescent local anesthesia may be better for us

How to stop causing Pain

Let every patient teach you- get them to score you
Ask them to tell you when the needle pain has stopped
Then again if they feel any new pain (drop shot for each pain – hole-in-one, eagle, birdie, par, bogie)
Wheelock study – no difference between dorsum or palm for pain of injection

Hole-in-one block

  • Slow
  • 5 mins to get hole in one
  • Need enough volume
  • Need to see or feel
  • 27g needle will force you to slow down – use 10 cc
  • pH
    • add 1cc Bicarb 8.4% ph 4.2 becomes 7.4
  • No alcohol prep (causes pain)
  • Push skin into needle rather than vice versa (sensory noise)
  • Don’t wobble
  • 2 hand technique
  • Thumb on plunger
  • Go perpendicular (90 deg)
  • Dont inject in dermis (If inject in dermis will see peau d’orange)
  • 2cc under skin, then wait
  • inject LA before advancing needle
  • “Blow slow before you go”
  • Feel where is the LA going
  • Needs to be 2 cm below where its going
  • If pink , not worked
  • Wait at least 30mins for block to work
7mg per kg old safe dose (1% Lidocaine plus 1:100000 Epinephrine)
therefore – for most adults – 50cc is safe
And can dilute down to 0.5% or even 0.25% (by using N/Saline)
Same LA effect, bigger volume can be used
May need to add more bicarb

Note –

1:1000 Epinephrine (e.g EpiPen) – will result in white digit for over 24hrs
Therefore should treat accidental epinephrine injections – ischemic re-perfusion pain, and ischemic neuropraxia  – so use phentolamine

For Lacerations

Inject directly into fat, through wound
Then slow – as above
Non sterile gloves okay for suturing injury lacerations

Tibial hematoma

60-80 cc with diluted 1/2 strength 1%lido
Blow the crap out of it


Don’t let exposed bone, joint tendon ‘dry and die’
Daily wash with clean bottle water
Vaseline cover to prevent drying
Must get vaseline off between wash and new vas

Finger tips

Secondary intent
wash with water
vaseline on Coban
Fingertip flap surgery can be problematic
Flaps cause log term problems, insensate, bulky etc
Although 2nd intent maybe slower initially, better in long run
Not if it crosses a joint


Metacarpal fracture – Only need ORIF if scissoring
for stable MC fracture
Splint – removable
?buddy taping
Patient info – “Don’t do anything that hurts”
No diff between flexed or extended

Tendon injuries

Please close the skin over injury then refer


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ED Rounds – September 2016

Report by Kraig Worrall

DMNB Clinical Clerk Med3



Pre-oxygenation for Intubation – Dr Jay Mekwan

Oxygenation is essential in the management of critically ill patients. Intubation in the emergency department is a critical skill in improving patient outcomes. When indicated, intubation should be performed by skilled personnel to minimize hypoxia. Desaturation in the peri-intubation period can happen quickly – particularly in pediatric, bariatric and critically ill patients. Today in rounds, Dr. Mekwan reviewed recent evidence in the realm of pre-oxygenation. Bag Valve Mask (BVM) pre-oxygenation alone outperforms: (1) BMV with concurrent nasal cannula, (2) non-rebreather mask, and (3) non-rebreather mask with concurrent nasal cannula. Using a nasal cannula together with BMV compromises the mask seal, which leads to inferior pre-oxygenation performance. A nasal cannula should be applied after BMV and before intubation and remain in place during the intubation process. Discussion in rounds centered around strategies to improve peri-intubation O­2 saturations, and ultimately improve outcomes in the Saint John Emergency Department. Finally, the use of ketamine in rapid sequence intubation was also discussed.






Blunt chest trauma – Dr. Andrew Lohoar

Although blunt chest traumas can present to the emergency department from a variety of etiologies, motor vehicle collisions and falls account for the majority of cases. This statistic holds true in Saint John, for which Dr. Lohoar presented some recent data (see slides). Several important conditions arising from blunt chest trauma were discussed, including lung contusion, hemothorax (HTX), cardiac tamponade and pneumothorax (PTX). In particular, discussion was centered around decisions surrounding chest tube placement for PTX and HTX. Emergency chest tube insertion is the definitive initial management for either of these potentially deadly presentations. The decision to place a chest tube in a hemodynamically stable patient with radiological evidence of PTX following blunt trauma is influenced by a number of factors. Today in rounds, we discussed how experience is paramount to successful chest tube placement. The balance between practitioner experience and patient’s need for urgent decompression must be considered. Complications from improperly placed chest tube can contribute significant morbidity. Initial observation of an otherwise stable patient can certainly be the right choice for emergency room staff with limited chest tube experience. The same can be true for patients requiring hospital transfer.

Additional teaching points included: the use of POCUS as part of the primary survey, the role of CT and CT-decision rules, the disposition of blunt chest trauma patients, and, finally, strategies to reduce complications when placing chest tubes.



Managing violent patients – Dr. Jo-Ann Talbot

For many patients, emergency departments are the gateway into medical care. This includes violent patients, who, despite their behaviour, are sick and in need of care. This presentation, by Dr. Talbot, described strategies for managing violent patients. Strategies when faced with a violent patient include; (1) Calling for help, (2) controlling the scene, (3) de-escalating the situation. Fundamental to de-escalation is recognizing signs of an impending crisis. As with other aspects of medicine, prevention is better than reaction. Recognizing a patient’s needs can prevent a violent episode, for example, a simple gesture of food, nicotine replacement, or medication can calm a tense situation, develop a therapeutic trust with the patient, and prevent physical violence.

When a situation moves beyond prevention, physical and chemical restraints become viable options to reduce harm to the patient, staff, and assets. When physical restraints are used, it requires a team of 5 trained individuals. If possible, the treating physician should not participate in restraining the patient, as this can be deleterious to the therapeutic relationship. Agents, dosing, and strategies for chemical restraint are reviewed in the attached presentation.

Finally, Dr. Talbot emphasized the need for a centre/region-wide protocol for violence in the ED that is understood and implemented by all staff.

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ED Rounds – May 2016

Imaging Decisions in Vascular Disease

Presented by Dr. Dylan Blacquiere (Neurologist)



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New Imaging Recommendations. Dr Jake Swan (Radiologist)

After meeting with Dr. Blacquiere and the ER department regarding stroke management and SAH management, I’m recommending the following based on new literature and evolving management in “high risk” patients.

1) High risk TIA patients, such as those who had a profound motor / speech deficit that is resolving should have a CTA carotid / COW as well as their standard CT head.

2) SAH patients should have CT done prior to LP due to false positive LP rates.  If there is any question about vascular malformation / aneurysm, follow with a CTA. The CTA isn’t necessary for every headache patient, etc, just those with a positive bleed on the unenhanced CT.

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ED Rounds – Dermatology – January 2016

Dr Todd Way presented a useful ED tool for identifying the majority of important dermatological diagnoses.

The rash is first categorised as belonging to one of the following four groups.

  • Petechial / Purpuric
  • Erythematous
  • Vesiculo-bullous
  • Maculopapular

The algorithms below are then easily used to produce  differential.






Try using this system with the 20 different rash diagnoses contained in Dr Way’s presentation

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ED Rounds – January 2016

The first ED rounds of 2016 were well aligned. Dr Chris Vaillancourt presented an update from his recent attendance to the American College of Allergy and Immunology Conference in Texas, and Dr Todd Way presented an interactive session on ED Dermatology.



The take home messages from Dr Vaillancourt’s presentation were:

  • Peanut introduction should be recommended between 4-11 months for high risk infants. See the LEAP study.
  • Ace Inhibitor induced Angioedema is mediated by Bradykinin (not Histamine) so Antihistamines / Steroids are unlikely to be effective.
  • Allergy_Update_-_CV_-_Jan_2016_pdf__page_18_of_32_
  • Consider nebulised (aerosol) epinephrine for symptomatic tongue swelling (see ref).
  • Consider Icatibant in cases where intubation may be required. A small study in the NEJM has provided some evidence of efficacy, although the control was questionable and the cost of the drug is very high.
  • Patients who present with anaphylaxis from a known food allergen are less likely to have a biphasic reaction, whereas those who present with either more widespread systemic reaction or the allergen is unknown may have a biphasic reaction and this reaction may occur later than previous guidelines suggest. A recent meta-analysis looked at  the Time of Onset and Predictors of Biphasic Anaphylactic Reactions. The median time to biphasic reaction was 11 hours (0.2-72 hours).

Dr Vaillancourt’s full presentation can be seen here

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Dr James French Presents – Elephant Trauma Rounds

An excellent presentation from Dr James French at Trauma Rounds this morning.

Take home messages:

  • New Brunswick needs a ‘Multiagency Trauma Research Registry’ in order to understand the problems and develop systems to address those problems
  • All doctors that work in Emergency Departments in all hospitals need to have ATLS certification at a minimum
  • Major Trauma is a relatively rare event. Training for major trauma must involve simulation. Simulation helps clinicians to become experts at managing rare events.
  • Most trauma deaths in New Brunswick occur in the 1st hour. The average transfer time to a Level 1 Trauma Centre is >1hr. Dr French welcomes the introduction of Advanced Care Paramedics in New Brunswick, but suggest that further Critical Care Paramedics skills are needed to perform the the emergency interventions required to reduce this early mortality.

Multiagency Trauma Research Registry

We already have some NB data on trauma cause and location. Download Dr Benoit Phelan’s  research poster here.


But we could do better. See this online visual database as an example of how it could be done.




Preparing for rare events (dealing major trauma is a relatively rare event for individual physicians and paramedics) requires ‘deliberate practice and mastery training’. Doing it again and again, practicing pitfalls, analysing mistakes, learning how to do it perfectly. The only way to do this is with simulation. Simulation needs to look and feel as close to reality as possible. Dress up – Cosplay!


Check Lists

How often have you struggled to quickly get your hands on the right equipment for a emergency procedure? Process mapping and planning assist in the development and maintenance of a system. Checklists augment clinical knowledge and training but do not replace it.

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Post RSI hemodynamic instability is common. Following a checklist can help to reduce complications of infrequently performed procedures.

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