Download CRITICAL CONCEPTS LSU SCHOOL OF MEDICINE

http://www.medschool.lsuhsc.edu/emergency_medicine/critical_concepts_rotation.aspx
Twitter: @emednola
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WELCOME TO CRITICAL
CONCEPTS
ROTATION OBJECTIVES:
 Provide all senior students with exposure to
acute and critical care concepts in a variety of
learning modalities.
 Review and reinforce diagnostic and
management skills in common and/or critical
disease entities and procedures encountered in
a range of specialties.
 Prepare senior students for their new roles as
resident physicians with direct patient care and
health care team responsibilities.
UNDERLYING PRINCIPLE

Every physician – regardless of specialty –
should know how to manage acutely ill,
undifferentiated patients with a variety of
emergent conditions
CLINICAL SCENARIOS: Case 1
JUNE 5, 2012
When suddenly …
“Is there a doctor on the plane?
your
picture
here
A 63 year old woman traveling alone in first
began shouting incoherently and wandering
around about ten minutes ago. Suddenly,
she slumps forward and becomes
unresponsive.
The flight attendant hands you a medical bag.
You are able to feel a weak radial pulse at
approximately 110 beats/minute and note a
respiratory rate of 8 breaths/minute.
CLINICAL SCENARIOS: Case 2
JULY 1, 2012
When suddenly … your pager
goes off …
A 60 year old man admitted to the floor got
up to go to the restroom. Suddenly, he fell
back into bed and became unresponsive.
The floor nurse goes out to find a code cart.
You are able to feel a weak radial pulse at
approximately 120 beats/minute and note a
respiratory rate of 10 breaths/minute.
CLINICAL SCENARIOS: Case 3
October 10, 2012
You are on your EM rotation on
a busy night shift when …
EMS brings in a 57 year old man who was an
unrestrained driver in a rollover MVC with
multiple cars. He was not responsive at the
scene.
Vital signs in the ambulance were HR 115, BP
100/60, and RR 10. All of the EM residents
are busy working up the other cars’
passengers.
WHAT NOW??

What would your immediate actions be
 In the air?
 If/when this happens to you on your first day of
internship?
 If you are the first medical professional caring for an
acutely ill/injured patient?

FOR EACH CASE - LIST 5 OF THE FOLLOWING:
 Initial actions
 Possible diagnoses
 Management/treatment steps
MANAGEMENT OF THE
ACUTELY ILL PATIENT
Based on the principles of identifying and
treating the immediate, life-threatening
conditions first
 All other considerations come second


KEEP IT SIMPLE
PRIMARY SURVEY
VITAL SIGNS = CRITICAL IMPORTANCE
HR
RR
BP
Temp
Pulse Ox
PRIMARY SURVEY
A – airway evaluation
 Are there any signs of obstruction?
○ FB
○ Masses
○ Trauma
INTERVENTIONS

RELIEVE THE OBSTRUCTION before
moving on
○ Finger sweep
○ Chin tilt/head lift or jaw thrust
○ Repositioning
○ Suctioning/hemorrhage control
 FUTURE AIRWAY PROTECTION?
PRIMARY SURVEY

B – breathing, oxygenation & ventilation
 Is the patient able to sufficiently oxygenate and/or
ventilate?
 Look for
○ Agitation/restlessness
○ Tachypnea/use of accessory muscles
○ Bradypnea/apnea
○ Breath sounds on BOTH sides
○ Tracheal deviation?
○ JVD?
PRIMARY SURVEY

Life threatening conditions requiring
immediate intervention
 Tension PTX
 Flail chest
 Respiratory failure/distress
○ Primary pulmonary issue
○ Consequence of underlying disorder
INTERVENTION:

Assisted oxygenation/ventilation through
○ Supplemental O2 (how much & how?)
○ Proper bag-valve-mask
○ Non-invasive positive pressure ventilation
○ Intubation (RSI) & mechanical ventilation
PRIMARY SURVEY

C – circulatory status
 Assess for PULSES (bilaterally) and heart tones
 Any obvious bleeding?
 Other s/s:
○ MS changes
○ Cool, pale extremities
○ Capillary refill
○ BP/HR – shock index
PRIMARY SURVEY

Life threatening conditions requiring
immediate intervention
 Shock states:
○ Hypovolemic?
○ Cardiogenic?
○ Distributive?
○ Obstructive?
 Active hemorrhage
INTERVENTION
Venous access (large bore/CVC)
 Administration of blood or fluid products in
rapid boluses
 Target to specific types of shock:

 Cardiogenic – inotropes, BP support, procedures
 Sepsis (distributive) – EGDT, source control
 Obstructive (PE/tamponade)
 Anaphylactic – epi, antihistamines
PRIMARY SURVEY

D – disability assessment
 Mental status/level of consciousness
 Gross neurologic exam
 Pupils
 GCS if trauma
INTERVENTION
Prompt imaging as warranted (trauma –
hemorrhage or fracture; medical –
CVA/mass)
 Prompt Neuro specialist involvement if
appropriate
 Reversal/supportive care if toxidrome
 Consider likelihood of airway protection
(“GCS less than 8 = intubate”)

PRIMARY SURVEY

E – FULL exposure
 Every inch of the patient is surveyed and




documented for obvious life threats
Occult traumatic injury
Infectious sources
Rashes/skin changes
Medications/patches
INTERVENTIONS
Imaging/tests/treatment based on findings
 Removal of any offending agent

After stabilization …
Brief, targeted HPI/PMH etc. (“AMPLE”)
 REASSESSMENT OF VITAL SIGNS and
success of any intervention
 Detailed testing
 Longer-term treatment and management
 Secondary survey: FULL PHYSICAL!

GOALS

… in the care of the undifferentiated
patient:
 Identify life-threatening processes
 Immediate stabilization
 Consideration of most serious and most likely
diagnoses
 Initiation of definitive treatment and care
 Utilization of all available resources when
appropriate
DON’T BE AFRAID …
This is fun!
ROTATION HOUSEKEEPING

Course structure and expectations;
 1 didactics week
 2 EM weeks
 1 ICU week

You are expected to be an active
participant in all parts of the course, and a
full member of each team
 (consider yourselves acting interns)
YOUR GOALS

What should you get out of this?
 Expanded skills and knowledge base from 3rd
year
 Application of those skills/knowledge to more
complicated/critically ill patients
 Increased exposure to/experience with common
and emergent procedures & interventions
 More sophisticated understanding of disease
complexity & health systems management

Most of you are here:
REPORTER

WHO
WHAT
WHERE
WHEN
We want to move you here:
INTERPRETER
MANAGER
HOW
WHY
WHAT NEXT?
DIDACTICS WEEK
Please read assigned material on website
prior to each session … come prepared to
discuss!
 Each of the 8 specialties has designed their
own interactive module on what they
perceive to be most important in managing
their most critical or common emergencies
 Each module requires a faculty/preceptor
signature

ICU ROTATION
You are an active part of the ICU team and
expected to have direct patient care and
documentation duties
 You should participate in family and team
discussions of care plans
 Details will differ between ICUs
 Information on where/when to report to
ICUs – see CC website under “Didactics
Schedule & ICU Information”

EM ROTATION
Again, you are expected to have direct
patient care responsibilities as part of
the EM team
 Please read the assigned EM readings during
your 2 week block
 While on the EM portion of the rotation,
you are expected to attend EM student
lectures and labs

SOCIAL MEDIA
Another part of the curriculum!
 Information available on the website – there
are several ways to have this information
“pushed” to you
 This content is testable!

CASE & PROCEDURE LOGS
During your EM block, please log all patient
encounters and procedures that you
observe, assist with, and/or perform into
E*Value
 If you have forgotten your logon/password
… please let Dr. Avegno know
 This is a way to begin to build your medical
portfolio

RESPONSIBILITIES
BE ON TIME … for all sessions, rounds, and
shifts
 Adhere to the school honesty policy at all
times
 Be properly supervised in all educational
and clinical settings and duties

EVALUATION METHODS

Final grade is based on:
 End of rotation on-line exam, derived from:
○ EM and specialty-specific reading (all online on
website)
○ Social media content
○ Didactic session lectures and labs
 Professionalism assessment during clinical rotation
H/HP/P/F system
 Either component can be remediated if
necessary

ATTENDANCE POLICY

Students may miss 2 days of the rotation FOR
INTERVIEWS ONLY:
 During EM block – may miss 1 ED shift and one
“free”day
 During ICU block – if 2 ICU days are missed, they
must be remediated the weekend before or after
(in order to have a full week of ICU)
 DIDACTICS DAYS MAY NOT BE MISSED

Please contact Dr. English or Dr. Avegno for
attendance questions
FORMS

Please turn in evaluation form to Jennifer
Jeansonne, course coordinator, upon
completion of the rotation (room 615)
NOW … ENJOY THE COURSE!