SHC – EM Reflections

Thanks to Dr. Paul Frankish for leading SHC EM Reflection rounds today.

Key Learning Points


Case 1:

Polytrauma patient with fluctuant GCS, tenuous airway in prehospital phase of care, transient hypotension in ED.


Learning Points:

  1. Rocuronium has slower onset than Succinylcholine.
  2. Consider redosing of sedation agent for intubation if significant time has passed since the last induction dose.
  3. Ongoing paralysis is rarely if ever indicated for transport, particularly if adequate sedation and analgesia have been accomplished.

Rapid Sequence Intubation


Case 2:

Polytrauma patient with severe agitation, hypoxia, and significant chest injuries.


Learning Points:

  1. Hypoxia and hypotension should be avoided if at all possible, in neurotrauma patients
  2. Chest tube pearls
    1. Obtain a cooperative patient (ie. pain control, sedation)
    2. Measure out depth of chest wall and diaphragm position with POCUS
    3. Large incision as needed
    4. Consider a “twisting screwdriver” motion on insertion (avoids fissure)
    5. Confirm placement in thoracic cavity by feeling chest tube alongside finger thru the intercostal space

Tube Thoracostomy


Case 3:

Patient with severe necrotizing infection and septic shock.


Learning Points:

  1. Consider using POCUS for rapid evaluation of shock patient
  2. Paralytic only intubation should be reserved for peri-arrest patients
  3. Beware subtle presentations of necrotizing infection in immunocompromised patients (Diabetes, immunosuppressants, neutropenia)

Case 4:

Pediatric septic shock


Learning Points:

  1. Differential diagnosis for a sick neonate is broad (THEMISFITS mnemonic) but sepsis is generally always at the top of the list
  2. Bradycardia in a severely ill neonate is generally a pre-terminal event
  3. If possible intravenous/intraosseous administration of antibiotics is preferred to the IM route
  4. Oxygenation of a spontaneously breathing patient with a BVM device requires several things to be successful:
    1. Adequate seal
    2. Adequate respiratory effort to open valve component
    3. PEEP valve to close off exhalation port preventing entrainment of room air

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