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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