Download A very distressed 4yo girl is brought by her father

A very distressed 4yo girl is brought by her father to your ED after she ignited her
clothes with a cigarefte lighter. She has partial thickness bums to her anterior neck,
chest, abdominal wall, and circumferential involvement of half her right upper limb.
Describe your management.
OR
A 2 year old child presents by ambulance with 50% burns to the lower half of the
body. Describe your management of this child.
ANSWER
Introductory paragraph
This child has significant bums and these will have to be dealt with on their merits.
Other important issues include analgesia, airway and breathing assessment, referral to
an appropriate burns service and consideration of non-accidental injury.
Treatment
This child has partial thickness burns involving 18% of body surface area. She will
therefore ultimately require transfer to a paediatric burns unit.
Reassurance to father and child.
Airway
—
Needs rapid assessment for risk of obstruction (history of smoke exposure,
deposits in mouth or nose, carbonaceous sputum) in view of anterior neck
and
chest involvement. Consider intubation with rapid sequence induction
using
suxamethonium and thiopentone if:
o Signs of imminent airway obstruction
o Hypoxia
o Oral erythema and / or blistering
o NB. Risk of leaving an involved airway is that there will probably be
progressive airway obstruction.
Breathing
—
—
—
high flow oxygen. Monitor breathing with resp. rate, work of breathing
and looking for cyanosis (late).
Chest full thickness esharotomy if restriction of ventilation.
Pulse oximetry may not be helpful if CO present
Circulation
—
—
—
2 IV cannulas preferably not in burnt areas / intraosseous if needed.
If shocked give fluid bolus of 2OmLIkg; repeat if necessary; blood
transfusion if shock continues (consider other injuries if this is the case).
Maintenance fluids plus:
—
Fluid replacement: 2-4mL/kgl% area: half in first 8 hours, half in next 16
hours. Hartmans or colloid can be used.
Intravenous analgesia as soon as possible morphine 0.1mg/kg and
—
repeat as required. Treat any injuries noted in secondary survey
Burns
—
—
—
—
—
—
Remove clothing
Clean bums
Saline soaked gauze until review by bums unit
Uruent referral to burns / surgical unit for:
o Consideration of eseharotomy if evidence of
compartment syndrome in right upper limb
Tetanus prophylaxis +1- Ig if immunisations incomplete
Avoid hypothermia
Other
—
—
Advice to father about fire safety
Consider non-accidental injury
Dis~sition
Transfer to a paediatric burns unit
NB. If ambulance transfer is necessary and there were concerns
regarding the airway, the safest practice may be to intubate the child
pre-transfer
A 32 year old woman is brought to your department unconscious from the scene of a
house fire. She is 34 weeks pregnant.
Paramedics found that her GCS was 3, PR 110, BP 120/80. She was intubated
by them without the use of drugs.
Her initial ABO results on 100% 02 are:
pH 7.05
mmHg
PO2 200
mmHg
H003 8
mmol/L
BE -15.
COHb 40%. (<5%)
a) Outline your ongoing management. (50%)
b) Discuss the role of hyperbaric 02 therapy in the treatment of this woman.
(50%)
a) Managemnet
KEY ISSUES:
1) 34/40 pregnant
a. 2 patients
b. Best fetal care is care of mother
c. Fetus is viable – must be consideration for delivery
2) Possibility of burns
3) Inhalational injury possible
4) Toxic inhalation from fire: carbon monoxide and cyandide most commonly
involved
5.) You are the sole physician in a coastal rural ED in far north Queensland,
300km from the nearest regional hospital. A 58yo man who collapsed shortly after
surfacing from a SCUBA dive is brought in by friends. He complains of severe
headache, abdominal pain and shortness of breath.
On examination, he is confused and agitated. BP 190/100, P 130. Outline your
a) assessment (70%) and
b) management (30%)
a) Assessment
Differential diagnosis:
This is cerebral arterial gas embolism until proven otherwise
Given SOB, ?did CAGE arise from pulmonary barotrauma
Given fast onset of Sx, this is most likely cause
Other main differential is type II decompression sickness
Given SOB, ?DCS with pulmonary (the chokes) and neurologic involvement
Consider marine envenomation
Consider differentials note related to diving
Focused history:
Diving history: onset of symptoms - ?during descent / during ascent / after ascent
Depth of dive
Duration of dive
History of decompression stops
Speed of ascent
Recent air travel
Type of O2 breathed
History of multiple dives
Sx history: neurologic symptoms: sensory or motor change, confusion, seizures, headache,
visual disturbance, gait abnormality, vertigo, tinnitus, nausea, vomiting
respiratory symptoms: SOB, chest pain, haemoptysis, cough
GI symptoms: abdominal pain, nausea / vomiting, diarrhoea / constipation
MS symptoms: joint pains
Relevant PMH: history of COPD / asthma that would predispose to gas trapping
History of previous complications from diving
Known ASD or PFO
RF’s for DCS: obesity, smoking, ETOH, exercise, cold, dehydration
DH
A
FH
SH
Focused examination:
A – assess airway
B – auscultate chest - decreased AE +/- deviated trachea to suggest pneumothorax
Hamann’s sign suggesting mediastinal air
Assess for subcutaneous emphysema
C – assess BP (patient significantly hypertensive), HR (tachycardic)
D – assess GCS; full neurological examination
?hemiplegia, altered LOC, altered vision, focal motor / neurological signs, nystagmus
?cognitive deficit or psychiatric symptoms
E – assess skin for any lesion to suggest envenomation
Relevant Investigations:
Bedisde: ECG to assess for cardiac arrhythmias or evidence of myocardial ischaemia
BSL
Lab: FBC, U+E, LFT, urine; ABG; coag, XM; CK is good marker of severity
Radiology: CXR for pneumothorax, mediastinal air, subC emphysema, intravascular air
CT head
b) Management
KEY ISSUES:
1) CAGE can be life threatening condition
2) Majority will recover with PROMPT recompression therapy – priority is to
achieve recompression
3) Recompression is unlikely to be available in rural ED – priorty will be for
early and safe transfer to 1Y facility with capabilities for this
Practical Issues
- Manage in monitored / resus bay
- Medics and ICU staff available
- Early contact with retrieval team
Resus
- 2x large bore IV cannulaes
- High flow O2 to SaO2 >94%
- Full NIPM
Trt
Treat in supine position, without leg elevation to minimize risk of further cerebral artery
aneurysm
A – maintain airway
B – high flow O2
- if pneumothorax – insert ICC; this is MANDATORY if patient going for
recompressive therapy
- if pneumomediastinum – supportive cares only
C – IV fluids – to maintain hydration, to prevent 2Y vascular ischaemic insults
Avoid dextrose as may exacerbate neurological injury
Arrhythmias are usually refractory to standard therapy
D – monitor GCS and neurological status closely
Mannitol only if suspect impending cerebral herniation
Lignocaine may improve outcome (48hr infusion)
E – monitor temperature, aim normothermia
Hyperbaric O2 is definitive treatment
- inform retrieval team and accepting hospital ASAP
- early treatment has better outcomes
- stabilize patient for transfer
- patient will require transport at sea level cabin pressure
A 49 year old power line technician is brought into your department by workmates who
describe seeing a flash of light near him and that he then fell 3 meters from a power-pole. The
incident occurred only minutes from your emergency department. He is unconscious. His BP
is 75/45 and his pulse rate is 130.
Outline your
a) assessment (40%) and
b) management (60%).
a) Assessment
Differential Diagnosis:
- High voltage AC electric shock has occurred resulting in:
- Blunt trauma – fall 3m from power pole, possibility of head, chest, abdominal or
spinal injuries
- Blast injury – can result in chest or GIT hollow viscera injury
- Thermal burns – likely extensive deep tissue involvement, regardless of skin
appearance
- Crush injury – significant risk of rhabdomyolysis
- Cardiovascular injury – myocardial injury highly likely given high voltage AC
current; with resulting arrhythmias
- Neurological injury – could be 1Y neurological insult or 2Y to hypoxic injury
Focused history:
Sx of condition: will need to be from bystanders
- Nature of current in powerline (voltage, ampage, type of current)
- Precautionary measures taken (eg. wearing hard hat, rubber gloves)
- Pathway of current – touched with hand?
- Duration of current – any witness of tetany and prolonged contact with line?
- Height of fall
- Mechanism of landing on ground (eg. head injury? Spinal injury?)
- Any history of seizure activity
- Initial assessment – initial GCS? Any bystander CPR? Initial obs on arrival of ambo?
- Pre-hospital management – rhythm strip? Any medications or interventions by ambo
Relevant PMH: known cardiac disease
Relevant DH: any cardiac medications
A
Relevant FH: cardiac disease
Relevant SH
Focused examination:
A: assess airway; assess for any evidence of facial/peri-oral/neck burns
B: assess breathing; any chest burns; any evidence of rib fractures / flail segment /
pneumothorax / haemothorax / pulmonary contusions; assess RR, WOB, SaO2
C: assess circulation; re-check BP; any signs of tamponade; any evidence of exsanguinating
trauma (external bleeding wounds; abdominal / chest injury, long bone / pelvic fracture)
D: assess GCS; assess neurological status; log roll for spinal injury; haemotympanum,
depressed skull fracture
E: assess skin; any burns; any evidence of compartment syndrome; entry and exit wounds
Investigations
Bedside: ECG (arrhythmias, ischaemic changes), BSL
Lab: FBC, U+E (high K), CK, LFT, amy, ABG, coag, XM, urine
Radiology: CXR, CT head / chest / abdo / pelvis
b) Management
KEY ISSUES:
1) This is life threatening injury
2) Blunt trauma, blast injury, thermal burn, cardiac injury, neurological injury as
above
3) Patient is tachycardic and significantly hypotensive – has a significant
underlying injury
4) Decreased GCS
Practical Issues
- in resus room
- trauma call out; surgical, ICU, medical staff
Resus:
- 2x large bore IV cannulae
- High flow O2 to SaO2 >94%
- Full NIPM
Trt:
A: maintain airway – assess GCS; if GCS <8 will require RSI (with sux and thio) and
intubation; assess for neck. perioral or facial burns
C spine precautions throughout
B: high flow O2; assess for sequlae of trauma as above
ICC if pneumothorax / haemothorax
C: IVF: 1L N saline rpt PRN for hypotension
If >2L saline required, resus with PRBC
Aim SBP >100, HR <100
Assume hypovolaemic shock until proven otherwise
Assess ECG: look for arrhythmias or ischaemic changes
Treat arrhythmias as per standard protocol
Following IVF resus, will require fluids as per burns injury: 2-4ml/kg/% burn
Aim UO 1-2ml/kg/hr
D: check BSL; assess GCS
Look for evidence of head injury
E: check T – aim normothermia
Assess for burns or evidence of compartment syndrome
Assess for cause of hypovolaemic shock – haemothorax, FF on FAST, pelvic injury, long
bone injury – treat cause if found
Remove smouldering clothes and jewellery
Complications:
- Compartment syndromes – monitor NV status of limbs closely
- Rhabdomyolysis – maintain UO and monitor urine
- Myocardial injury – ECG monitoring required
- Deep tissue burns
- Vascular injury – vasospasm, aneurysm formation, delayed bleeding
- Blast injury – perforation
Ongoing trt:
Monitor acid-base balance
Close monitoring of fluid including provision of maintenance fluids
Urinary catheter
Ongoing ABCs
Monitoring for complications as above
Temperature
Disposition
Admit to ICU for ongoing monitoring and management of complications
Need to talk to workers as this will have been traumatic experience
SAQ 7
“A 38 year old man is brought in by ambulance. He was found unconscious in a house fire by
the
fire brigade. He is now conscious with spontaneous respirations and has O2 being delivered
via a Hudson mask at 6L/min. He has a black sooty face and head. Both his hair and nasal
hair are
singed. He has carbonaceous spots on his tongue and pharynx. There is circumferential
blistering
to his left leg.
a.Outline your management of this patient (70%)
b.Discuss the use of hyperbaric oxygen in this case. (30%)”
The overall pass rate for this question was 41 / 69 (59.4%)
The expected answer to the management part of this question included a number of issues.
Although
upper airway compromise was perhaps the most obvious the examiners felt that many other
issues
needed to be addressed including consideration/management of lung injury, blast trauma,
noxious
gas exposure, fluid resuscitation, circumferential leg burns/limb viability and the need for
transfer to
a specialist unit. Highlighting these issues was not easy if a candidate took a formulaic EMST
approach. In the discussion part of the question it was expected that a candidate would display
an
awareness of the current research and debate on the subject of HBO use in CO poisoning as
well as
the specific logistic issues that it may present in this case. Failing candidates tended not to
deal with
the detailed issues in question a) and then appeared to tackle b) only as an afterthought.
SAQ 177
A 55 year old bushwalker has been rescued after several days in the open. On arrival in
your ED his vital signs are as follows:
P 40
BP 80 / 40
GCS 13
Rectal temp 29'C
Discuss the options available for rewarming a patient with severe hypothermia,
including a discussion of the risks and complications of each technique.
He is suffering form severe hypothermia (failure of thermoregulation), This may be purely
from exposure or related to another process eg sepsis
Handle gently ( may ppt VF)
A Oxygen, secure airway. Indication for intubation same as normal (risk of intubation induced
arrhythmias is low)
B
C Hydrate with warm saline
D
E Core temp needed with low reading thermometer (rectal probe)
Drugs Thiamine is alcohol suspected
Antibiotics, steroid and thyroxine not routinely administered unless suspected cause
Rewarming
No prospective studies done in human to compare different treatments
If cardiovascular stable, even with low temp then some argue not for rapid rewarming and use
non-invasive methods (warm fluid and O2)
Others argue rapid rewarm until 30-32'C as they could develop arrhythmia
Passive at scene (removal from cold and insulation)
Active external (warm water immersion, bair hugger, heaters)
idosis from periphery and > BMR of tissue before
heart rewarmed to cope)
Active internal
Advantage is preferential warming of central organ eg heart, decreasing irritability and
normalizing CO early. Peripheral vasodilatation avoided and decreased incidence of core
temperature afterdrop, rewarming acidosis, shock
• Intubation rewarming minises heat loss from lung but does little to rewarm
• Warm fluid (experiments with hot fluids awaited)
• GIT/bladder lavage. Needs airway protection at risk of aspiration
• Peritoneal lavage. Rapid rewarming can be achieved. Use K free dialysis solutions
• Pleural lavage. Left side. Use 2 tubes .Watch for tension hydrothorax
• Bypass and haemodialysis. May need heparinisation
• Mediastinal irrigation via thoracotomy
SAQ 316
A 55-year-old electrician presents after being electrocuted whilst working on a
domestic power supply. He complains of right arm pain and palpitations.
(a) Outline your assessment of this man. (70%)
(b) Outline the options for this man’s disposition. (30%)
Key Issues:
• Domestic power supply – probable 240V / 50Hz AC
• Palpitations: potential cardiac injury
• Right arm pain: ?burn, ?electrical injury to muscle etc
(a) Assessment:
History:
• Circumstances of incident:
o Time, protective equipment/clothing worn, contact point, duration of contact, path of current
flow.
o Confirm power supply type
o Any associated fall, explosion, fire
o Any loss of consciousness
• Symptoms of injuries:
o Palpitations – ?compromised - any associated chest pain, pre-syncope, SOB
o Right arm – location of pain, any numbness, weakness or parasthaesia
o Any other complaints
• Past history:
o Any cardiac disease – previous arrhythmias
• Medications, allergies, tetanus status
Examination:
• Vital signs
• Assess for immediate life threats:
o Airway and breathing –
– GCS 15
o Circulation –
– any compromise from palpitations
o Disability –
• Systems examination:
o Right upper limb – neurovascular assessment; evidence of compartment syndrome, or
fracture/dislocation (esp: shoulder – posterior dislocation); any evidence of burns
o Assess for entry and exit wounds
o Assess for other injuries and burns
Investigations:
Bedside:
• BSL
• ECG - arrhythmia especially sinus tachycardia, AF, ectopics, ST or T wave changes,
myocardial ischaemia
• WTU - +ve RCC (?myoglobin)
Laboratory:
• FBC - baseline
• ELFT- esp: hyperkalaemia, baseline renal function
• CK - rhabdomyolysis
• Troponin I (if abnormal ECG) – myocardial injury
• Urinary myoglobin – if elevated CK (x3 times normal)
Radiology:
• CT head – if episode loss of consciousness / or other secondary injury suspected
• Xrays - of limbs or other as examination findings indicate.
(b) Disposition:
• Majority of domestic power (240v) electrocutions can go home with analgesia and planned
follow up of minor injuries or burns.
o Need to have symptoms resolve
o Normal ECG in sinus rhythm
o No significant burns or soft tissue injury
• Will require admission to hospital for cardiac monitoring if:
o Abnormal ECG (+/- elevated troponin) - arrhythmia, ECG otherwise abnormal (as above)
until normalises.
• Will otherwise require admission if has:
o Neurovascular deficits to right upper limb
o Suspicion or evidence of compartment syndrome to right arm
o Significant burns (large or deep or to special area ie: hand) or other significant injuries
requiring inpatient management or iv analgaesia
o Evidence of rhabdomyolysis
SAQ 034
A previously healthy 35 year old man arrives in your ED after collapsing during a
marathon. He is having a generalised clonic convulsion. His vital signs are:
P 140
BP 100/70
Temp 42'C
Outline your management.
Diagnosis of probable exertional heat stroke (classically >40'C, anhydrosis, CNS
dysfunction). Sweating may be present. Differential still contains sepsis, intracranial bleed etc
A Secure airway.O2
B
C Hydration with isotonic
D Stop the fit. Use benzo
E Insert thermometer
Ix to ID endorgan failure FBE, ELFT, COAG, Ca, Mg, Urine (for myoglobin), toxicology screen
CXR, ECG
CT head, LP
Rx
Cooling technique
Evaporation is rapid and non-invasive (spray pt with water and use fans)~0.3 - 0.03C/min
cooling Complication are shivering and problems keeping electrodes on body.
Strategic ice pack cooling (alone 0.028C/min, or with evaporation 0.034C/min) Ice packs are
placed in the axillae and groin
Immersion cooling (0.27-0.14C/min) complication are detachment of leads, shivering, inability
to defibrillate or do resus
Cooling should be stopped when temp <40'C as it may lead to over shoot hypothermia.
SAQ 317
A 25-year-old man, with no pre-morbid history, has been brought to your emergency
department after completing a half marathon. He was found fitting shortly after
finishing the race. Ambulance officers have administered 5mg midazolam
intramuscularly at the scene, and his seizure has ceased. His temperature is 42.5'c.
Outline your management of this patient (100%)
• 25yo male
• Seizure post excessive exertion
• Hyperthermic
Differential diagnosis for this presentation includes:
• Heat stroke – most likely diagnosis
• Other differentials for hyperthermia (investigate and manage for if assessment dictates):
o Sepsis
o Prolonged seizure – underlying epilepsy
o Drug induced/interaction – SSRI, MAO inhibitors, phenothiazines, stimulants
Management:
Triage to resuscitation room
Assemble resuscitation team
Connect to comprehensive non-invasive monitoring
Apply high flow O2 via NRBM
Identify and manage any immediate life threats.
Airway and breathing
• Assess for a patent and protected airway
• Level of consciousness may be depressed for a variety of reasons (post-ictal, im
midazolam, heat stroke itself) – if required assist ventilation. If no early signs of improvement
in conscious state – RSI to intubate and ventilate to provide protected airway.
• Assess RR, breath sounds, SaO2 – if unable to maintain oxygenation or ventilation by other
means intubate and ventilate.
Circulation
• Assess HR, BP, peripheral perfusion
• IV access x2 large bore cannulae
• IV 0.9% saline 20ml/kg to correct hypotension and restore circulatory function if required
Disability
• Assess GCS, pupillary reaction.
• Any evidence of ongoing fitting – treat with further midazolam iv 2.5mg boluses titrated to
effect
Obtain BSL – treat hypoglycaemia with 1ml/kg 50% dextrose
Confirm temperature of 42.5 degrees.
• Begin active external cooling:
o Expose patient
o Tepid water spray and fan for evaporative loss
o Ice packs to major vessels – neck, groins, axilla
Further supportive treatment:
• Maintain oxygenation – aim SaO2>96%. If ventilated aim PaCo2 ~40mmHg
• NGT if intubated
• Continue fluid resuscitation with 0.9% saline 20ml/kg boluses – aim for BP>100 and restore
circulatory function / peripheral perfusion
• IDC with temperature probe – q1hr measures. Monitor response to fluid resuscitation. Aim
1ml/kg/hr
• Continue active external cooling until core temp is 38 degrees
• If further seizure activity despite midazolam and cooling – load with iv phenytoin 20mg/kg.
Will require intubation and ventilation (if not already) if uncontrolled seizures
• If intubated – avoid long acting muscle relaxants to monitor for further seizures. However if
temperature not falling and shivering becomes problematic – paralyse and monitor EEG
• Largactil iv 12.5mg titrated to effect also useful to settle shivering
Further specific treatment:
Identify and treat complications of hyperthermia:
• Rhabdomyolysis
o Aggressive fluid resuscitation as previous
o Aim UO >2ml/kg/hr
o If CVS stable – 0.5g/kg iv mannitol to assist diuresis and act as free radical scavenger
• Coagulopathy
o Correct abnormal coagulation profile with FFP
• Electrolyte abnormalities
o Hyperkalaemia – 10mmol Ca Gluconate if cardioprotective effect required; otherwise 10u
insulin / 50ml 50% dextrose; 1mmol/kg 8.4% NaHCO3; resonium 15g retention enema
• Acute renal failure
o Observe for anuric ARF – will require haemodialysis
Disposition:
• Will depend on condition and response to initial resuscitation
• ICU – if intubated; or ongoing CVS instability / severe rhabdomyolysis, coagulopathy,
electrolyte disturbance
• Otherwise general medical ward with close observation
SAQ 040
A 50 year old man presents to your small Emergency Department after flying home
from a scuba diving holiday, complaining of back pain and weakness/paraesthesia in
both legs. There is no history of trauma or of previous similar problems.




What is the most likely diagnosis ?
What are the risk factors for this condition ?
List the differential diagnosis
Discuss any important principles governing the transfer of this man to a
tertiary referral centre 300 km. away.
Predisposing factors
Advanced age (decreased tissue perfusion)
Obesity (decreased absorption of inert gas)
Dehydration
Drunk and dehydrated
Cold water
Exertion (increased gas uptake)
Local physical injury
Multi-dives (gas build up)
Ascent to altitude ( including flight)
Dive related DCI
Not related to dive
Spine related
Musculoskeletal (muscle sprain)
Disc pathology
Non spine related
AAA
Renal pathology
Respiratory (pneumothorax)
Pancreatitis
Needs air transport pressurized to 1 atm ( or non pressurized <300km) or portable
recompression chamber (none in Oz)
Road transport not suitable as too far and watch for ascents over 300m
SAQ 493
A 38 year old man is brought in by ambulance. He was found unconscious in a house
fire by the fire brigade. He is now conscious with spontaneous respirations and has 02
being delivered via a Hudson mask at 6L/min He has a black sooty face and head. Both
his hair and nasal hair are singed. He has carbonaceous spots on his tongue and
pharynx. There is circumferential blistering to his left leg.
a. Outline your management of this patient (70%)
b. Discuss the use of hyperbaric oxygen in this case. (30%)
The overall pass rate for this question was 41 / 69 (59.4%)
The expected answer to the management part of this question included a number of issues.
Although upper airway compromise was perhaps the most obvious the examiners felt that
many other issues needed to be addressed including consideration/management of lung
injury, blast trauma, noxious gas exposure, fluid resuscitation, circumferential leg burns/limb
viability and the need for transfer to a specialist unit. Highlighting these issues was not easy if
a candidate took a formulaic EMST approach. In the discussion part of the question it was
expected that a candidate would display an awareness of the current research and debate on
the subject of HBO use in CO poisoning as well as the specific logistic issues that it may
present in this case. Failing candidates tended not to deal with the detailed issues in question
a) and then appeared to tackle b) only as an afterthought.
SAQ 039
An 18 month old boy is pulled from a swimming pool after being left unattended for
two minutes. His vital signs are:



GCS 8
P 100/min
BP 75/45

SaO2 85% on 6 l O2 /min via face mask
You attend the scene as part of an Emergency Department retrieval team. The scene is
fifteen minutes from the hospital by ambulance. Outline your management.
This will be an unfamiliar environment for Emergency staff. Ambulance officers are highly
skilled in pre-hospital care, take their lead. Ensure it is a safe environment to work in.
Consider why a medical retrieval team has been requested; for example long scene time
expected or advanced airway skills.
1.Prior Preparation



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Equipment – Curved Laryngoscope – blade size 1 & 2
ETT – 3.5, 4, 4.5,
Estimate weight – 11.5kg
Drug dosages and fluid bolus calculations
Note normal vitals signs for this age: HR 130 – 120, BP 100 systolic +/- 30, RR 20 –
30
2. Role Allocation




QAS officer – scene leader
Doctor – resuscitation team leader – management of airway, assistance with securing
iv access
Nurse – assist with procedures/scout
4th person if available – allocate to parents – support and gather information
3. Resuscitation at Scene….

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
Safety
o Consider any safety aspects of scene eg dog, electrical wires, water on
ground making surface slippery
o A public swimming pool may require crowd management
Airway
o Ensure patency – head lift, jaw thrust
o Consider airway adjuncts
o NPA – tip of nose to tragus of ear
o Guedel – incisor to angle of mandible
Breathing
o Assisted breaths with Bag Mask Ventilation with 100% oxygen, apply PEEP if
able to with PEEP valve on air-viva
o Consider urgency in securing the airway especially if GCS if rising
o Intubating this child is likely to require muscle relaxants/sedation and ongoing
drugs; the hospital only 15 minutes away. If scene time is anticipated to be
short and simple measures improve saturations hold off until hospital
environment.
Circulation
o 1 x peripheral ivc in antecubital fossa
o IO needle if unable to obtain ivc in 5 minutes
o fluid bolus – 20ml/kg (~250ml N/Saline bolus) and assess response by cap
refill, HR and BP. Repeat as needed
o Attach ECG monitoring, interpret, treat any arrhythmia as per ACLS
guidelines
o Continually reassess PR, BP and rhythm.
Disability
o Early BSL, treat if appropriate 5ml/kg of 10% Dextrose
Environment
o Remove wet clothes & dry infant
o
o
o
o
o
Gather information – time missing, clinical status when found,
commencement of BLS, seizure activity, PMHx, Meds, Allergies, Hx of
trauma
Ring ahead with expected time of arrival and activate a Paediatric
Resuscitation team
Talk to parents
Consider if there is room for a parent in ambulance
Transport to hospital expeditiously but safely
4. Hospital Care….

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

Staff to have prepared while you are at retrieval – drug dosages, equipment
Resuscitation
A/B
o RSI after good volume resuscitation
o Atropine premedication (0.02mg/kg) = 0.23mg (~.2mg)
o Suxamethonium (2mg/kg) = 2.3mg
o Fentanyl (2mcg/kg) = 23mcg
o Midazalam (0.1mg/kg) = 1.15mg
o Acute Lung Injury ventilation strategies: 6mls/kg at a rate of 15 -20 bpm,
o Early CO2 monitoring
o Monitor with ABG,
o check position with CXR
CVS
o Fluid bolus 20ml/kg
o +/- Ionotropes
5. Supportive Cares
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Ongoing sedation
Draw up Midazolam (2mg/kg) & Morphine (1mg/Kg) make up to 50ml with Normal
Saline, start at 1 ml/hr (Midazolam 40mcg/kg/hr and Morphine 20mcg/kg/hr), titrate to
effect up to 5ml/hr
NGT: 5 Fr feeding tube for early gastric decompression of swallowed water
Hypothermia (aim for 32 – 35 degrees) in consultation with local PICU
Treat seizures as they occur (midazolam 1.15mg iv)
Electrolytes – monitor and correct
Prophylactic abs not recommended including if temperature in first 24hours
IDC: 5 French, aim for urine output of ~12 ml/hr
Support Family – Social Work
Consider NAI/neglect and refer appropriately
Treat any underlying cause – seizure, intoxicants and arrhythmia
6. Disposal

PICU – may require transfer, if so activate and prepare
7. Media Management

Public safety message re: water safety
8. Debrief and Audit
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


Thank staff for a job well done
Debrief staff (hospital and ambulance)
Audit times
Follow-up clinical course and feedback to staff

Note any improvements for next time and implement
SAQ 042
A man is brought to your Emergency Department after an accident in a quarry, when
an explosive charge which he was setting went off prematurely. Outline the different
classes of blast injury. Outline the specific injuries which could occur in this situation.
1. Primary: Blast wave
2. Secondary Blast: Flying debris
3. Tertiary: Bodily displacement
4. Miscellaneous: Inhalation of dust, burn, radiation, toxic gas
ENT
Ears Membrane rupture at 300 mmHg, dislocation ossicles, inner ear damage (perlymph
fistula)
Tinnitus and vertigo with hearing loss
Barotrauma to sinuses (cf squeeze)
Pulmonary
Blast lung
Pneumothorax
Haemorrhage
Air emboli
Pulmonary oedema
GIT
Multifocal damage at tissue/air interface
Worse in large bowel as more air. May result in perforation and peritonitis
Evisceration is nearly always fatal
CNS
Concussion syndrome from shock wave (+ bleeds)
Air emboli syndrome
Other
Consider toxic inhalation (misc injuries)
Observe 6-12 hrs for delayed presentation especially if ear drum perforation (indicative of
significance of force)
SAQ 045
You receive notice that five U.S. Navy sailors are being brought to your Emergency
Department following an offshore accident on board a nuclear powered submarine.
They are said to have been exposed to an unknown dose of radiation during a
malfunction of the reactor core. They are all vomiting profusely.
(a) Outline your preparation for this situation (50%)
(b) Outline your management of the patients (50%)
Assume these patients have been exposed to a life-threatening dose of neutron radiation
• Prodromal phase of acute radiation syndrome manifests as anorexia, nausea, vomiting,
diarrhea, fatigue, hypotension and diaphoresis
Critical issues
• Staff safety
• Implementation of hospital radiation exposure plan
• Estimation of radiation dose
• Supportive care
(a) Preparation:
Emergency department preparation:
• Implement radiation exposure plan
o Including notification of hospital radiation officer
• Contact radiation specialist for assistance
o Australian government agencies
o Appropriate US Naval authorities
• Separate, controlled entrance
• Designated decontamination area
o No pregnant women, non-essential personnel or equipment
o Establish boundaries that demarcate “clean” from contaminated areas
o Separate water run-off and air conditioning supply
• Designated emergency response team
o Appropriate senior medical and nursing staff
o Staff to wear standard protective clothing with dosimeters attached to outside (5 rad limit
and timed breaks)
• Obtain further information from Ambulance
o Circumstances of accident
o Identification of radioactive material
o Possible exposure to other potentially toxic materials
(b) Management:
Upon patient arrival:
• Emergency response team to meet ambulance outside the ED
o If patient medically stable, transfer to decontamination area
o Emergency intervention should not be delayed because of contamination
• All clothing and personal items should be removed and placed in labelled waste containers
o Monitor all metal objects for induced radioactivity
• Irrigation with warm water if exposed to radioactive fluid or particulate matter
• No persons, equipment or material should leave the decontamination area until cleared by
radiation safety officer
Specific management
• Comprehensive non-invasive monitoring with immediate attention to life-threatening
cardiorespiratory complications
• Administer 15 litres O2 via non-rebreathing mask
• Intubation / ventilation if impaired consciousness –unable to protect airway
o Patients with significant CNS and CVS dysfunction have 100% mortality
• 2 x 16g IV cannulae
• Send blood for baseline FBC and differential, urea and electrolytes, cell and HLA typing (if
required)
• IV saline 0.9% 20ml/kg bolus – aim SBP >100mmHg
• Antiemetics – metoclopramide 10mg IV
• Analgesia – morphine 0.1mg/kg IV (titrate to pain relief/anxiolysis)
• Supportive treatment
o Maintenance fluids - IV saline 0.9% 125ml/hr – titrate to achieve urine output 0.5ml/kg/hr,
HR<100, systolic BP>100
er inotropic support for refractory hypotension
o Correct any electrolyte disturbances
o Maintain normothermia
o Treat any other conditions
• Disposal
o Admission to intensive care facility
o Monitor lymphocyte count
- universally fatal
– severe clinical course
– good prognosis
o Often have symptom free latent phase followed by manifested illness phase
o Other treatment includes
TPN
• Media
o Involve hospital, Australian government and US Navy in media liaison