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CRITICAL CONCEPTSLSU SCHOOL OF MEDICINE
SENIOR ROTATION 2011-12
http://www.medschool.lsuhsc.edu/emergency_medicine/critical_concepts_rotation.aspx
Twitter: @emednolaFB: LSU-EM @ NOLA
WELCOME TO CRITICAL CONCEPTSROTATION 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
JUNE 5, 2012 / JULY 1, 2012
When suddenly …
“Is there a doctor on the plane?/in the ward?” your
picturehere
A 63 year old woman traveling alone in first class/admitted to the floor began shouting incoherently and wandering around about ten minutes ago. Suddenly, she slumps forward and becomes unresponsive.
The flight attendant/nurse 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.
WHAT NOW??
What would your immediate actions beIn the air?If/when this happens to you on your
first day of internship?
LIST 5 OF THE FOLLOWING:Initial actionsPossible diagnosesManagement/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
HRRRBPTempPulse Ox
PRIMARY SURVEY
A – airway evaluationAre there any signs of obstruction?○ FB○ Masses○ Trauma○ TONGUE
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 & ventilationIs 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 interventionTension PTXFlail chestRespiratory 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)
PRIMARY SURVEY
C – circulatory statusAssess for PULSES (bilaterally) and
heart tonesAny obvious bleeding?Other s/s:○ MS changes○ Cool, pale extremities○ Capillary refill○ BP/HR – shock index
PRIMARY SURVEY
Life threatening conditions requiring immediate interventionShock 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 assessmentMental status/level of consciousnessGross neurologic examPupilsGCS 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 exposureEvery inch of the patient is surveyed
and documented for obvious life threats
Occult traumatic injuryInfectious sourcesRashes/skin changesMedications/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 processesImmediate stabilizationConsideration of most serious and
most likely diagnosesInitiation of definitive treatment and
careUtilization of all available resources
when appropriate
DON’T BE AFRAID …
This is fun!
ROTATION HOUSEKEEPING
Course structure and expectations;1 didactics week2 EM weeks1 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 yearApplication 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:
We want to move you here:
REPORTER
INTERPRETERMANAGER
WHOWHAT
WHEREWHEN
HOWWHY
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”dayDuring 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!