Where did the IV fluid go…

DID YOU KNOW: In managing shock, for every liter of normal saline given, only 180mls remains intravascular (your normal adult intravascular volume is approx. 5L). So in hypovolaemic patients…give loads of fluids…for blood loss, give blood early, the best natural colloid.

Treatment of Seizures in the ED

Although most seizures resolve spontaneously in one to three minutes, the seizures we typically face in the emergency department are the generalized tonic-clonic type and have been going on for a longer period of time, usually fulfilling the Neurocritical Care Society guidelines’ criteria for status epilepticus—a continuous seizure lasting more than five minutes, or two or more seizures within a five-minute period without return to neurological baseline in between. We know status epilepticus is associated with a mortality rate as high as 43 percent, and as the duration of seizures increase, the outcomes become poorer, especially in seizures lasting more than 30 minutes, owing to brain anoxia, acidosis, and rhabdomyolysis that occurs with ongoing seizure activity. In fact, the seizure duration is the only potentially modifiable determinant of mortality. It is believed that the longer the seizure, the more refractory to medication it becomes.

Detecting Child Abuse in the Emergency Department

  1. When there is concern for physical abuse, the physical examination should be completed with the child undressed (in a gown), with specific attention to the skin, scalp and fontanel, mouth and oral cavity (including frena), ears, genitalia, and growth chart.
  2. Any injury in a preambulatory child, including bruises, mouth injuries, fractures, and intracranial or abdominal injury, should raise concern for abuse.
  3. The “TEN 4” rule: bruising of the Torso, Ears, or Neck in children <4 years old and any bruising in children <4 months old should raise concern.
  4. Radiographic skeletal survey should be performed using proper technique for children <2 years old with concern for abuse. Repeating the skeletal survey 2–3 weeks later can identify additional fractures that were not seen initially.
  5. Young (<2 years old) siblings and household contacts of abused children should be examined for abusive injuries and undergo skeletal survey.
  6. Infants evaluated for physical abuse may benefit from neuroimaging even if they don’t have neurological symptoms.
  7. Retinal examination is indicated for children with concern for abusive head trauma but may not be indicated for children without intracranial injury.
  8. Health care providers with a reasonable suspicion of physical abuse have a legal mandate to report their concern to child protective services.

Top 5 things to do prior to discharging a patient

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  1. Shake the patient’s hand: There’s no better feeling than stopping over to say goodbye to a patient who is dressed, energized, and fully ready to leave with a clear understanding of medical decision making, return precautions, and follow-up plans.
  2. Trust your instincts: Our responsibility doesn’t end when the patient leaves those department doors. We are obligated to protect our patient in the emergency room as well as AFTER they are discharged.
  3. Read over the chart: Skim the triage summary, vitals, and the notes. double-check reads on imaging/labs and repeat vitals, since the worst feeling is to discharge a patient with a documented HR of 120 or a incidental nodule on chest-xray that you never told the patient about.
  4. Examine your patient (twice is better than once): repeat physical exam, vitals, and further probing of history (with appropriate associated documentation as well).
  5. Check to see that the patient can eat, talk, walk, poop, and pee.

Oxygen…THE DRUG!

DID YOU KNOW:

  • Hospital Oxygen is NOT FREE
  • At an SPO2 of 94%, additional oxygen is of NO BENEFIT. At this level, the standard dissociation curve is relatively flat, which means that the oxygen content of the blood does not change significantly even with large increases in oxygen.
  • Oxygen DOES NOT CURE DIFFICULTY IN BREATHING (DYSPNOEA), just HYPOXIA.
  • Oxygen should be delivered to achieve a target saturation of 94–98% for most acutely ill patients or 88–92% for those at risk of hypercapnic respiratory failure e.g. COPD
  • Humidification of supplemental oxygen commonly delivered by bubbling oxygen through either cold or warm sterile water before it reaches the patient should NOT be used because there is NO EVIDENCE of a clinically significant benefit but there is a risk of infection.

DOSE:

  • Nasal prongs delivers 4% additional oxygen per 1 litre of flow i.e. at 1L/min it delivers 24% (20% is already in the air), at 2L per min it delivers 28%, 3L/min 32%…and so on so at 6L/min it delivers 44%
  • A simple face mask should be used at a minimum of 6L/min (normal minute ventilation) to prevent the patient from breathing back their own CO2.
  • Application of a self inflating Bag-Valve-Mask on a patient’s face without compressing the bag is called suffocation. Due to the valves system, oxygen is only delivered ON COMPRESSING THE BAG
  • Pulse oximeters consist of two light-emitting diodes, one in the red range and one in the infrared range, and a detector.  Oxygenated and deoxygenated haemoglobin absorb light at different wavelengths differently. Deoxygenated or ‘‘blue’’ blood absorbs light maximally in the red band, whereas Oxygenated or ‘‘red’’ blood absorbs light maximally in the infrared band. The ratio of absorption of the two wavelengths of light are then compared with an algorithm in the microprocessor generated by empirically measuring the absorption in healthy volunteers at varying degrees of directly measured arterial oxygen saturation. The displayed value is usually an average based on the previous 3 to 6 seconds of recording.

HARMFUL EFFECTS:

  • Nonhypoxic heart attack victims treated with oxygen endure a 25 to 30% more heart damage than patients not given oxygen
  • Oxygen supplementation to nonhypoxic patients with mild or moderate strokes may increase mortality.
  • High-dose oxygen therapy to produce hyperoxaemia (above normal oxygen saturation) can cause absorption atelectasis
  • Oxygen is liberally administered to many critically ill patients, thereby exposing them to supranormal arterial oxygen levels.
  • Hyperoxia also results in the formation of reactive oxygen species, which adversely affect the pulmonary, vascular, cnetral nervous, and immune systems.
  • Though the optimal PaO2 remains unknown, recent evidence indicates that hyperoxia is associated with increased mortality in post-cardiac arrest, CVA, acute coronary syndrome, and traumatic brain injury patients.
  • Take Home Point: Carefully titrate oxygen to the lowest tolerable level to meet the patient’s needs.