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:
- Rocuronium has slower onset than Succinylcholine.
- Consider redosing of sedation agent for intubation if significant time has passed since the last induction dose.
- Ongoing paralysis is rarely if ever indicated for transport, particularly if adequate sedation and analgesia have been accomplished.
Case 2:
Polytrauma patient with severe agitation, hypoxia, and significant chest injuries.
Learning Points:
- Hypoxia and hypotension should be avoided if at all possible, in neurotrauma patients
- Chest tube pearls
- Obtain a cooperative patient (ie. pain control, sedation)
- Measure out depth of chest wall and diaphragm position with POCUS
- Large incision as needed
- Consider a “twisting screwdriver” motion on insertion (avoids fissure)
- Confirm placement in thoracic cavity by feeling chest tube alongside finger thru the intercostal space
Case 3:
Patient with severe necrotizing infection and septic shock.
Learning Points:
- Consider using POCUS for rapid evaluation of shock patient
- Paralytic only intubation should be reserved for peri-arrest patients
- Beware subtle presentations of necrotizing infection in immunocompromised patients (Diabetes, immunosuppressants, neutropenia)
Case 4:
Pediatric septic shock
Learning Points:
- Differential diagnosis for a sick neonate is broad (THEMISFITS mnemonic) but sepsis is generally always at the top of the list
- Bradycardia in a severely ill neonate is generally a pre-terminal event
- If possible intravenous/intraosseous administration of antibiotics is preferred to the IM route
- Oxygenation of a spontaneously breathing patient with a BVM device requires several things to be successful:
- Adequate seal
- Adequate respiratory effort to open valve component
- PEEP valve to close off exhalation port preventing entrainment of room air
