1. CRITICAL CARE TIPS & TRICKS Dr. Matthew Inwood

2. Disclosures  None

3. Objectives  Identify & discuss procedural techniques and therapeutic modalities to improve quality of care & patient safety when caring for the critically ill.  Identify & discuss therapeutic modalities to improve efficiency & optimise resource utilisation in the Emergency Department.

4. Case #1  38 y.o male, found unresponsive at the bus station, with an empty oxycontin Rx container in his hand.  Pin-point pupils, SaO 2 94%, GCS 11.

5. Case #1  Re-assessed 60 minutes later…  SaO 2 90%, occasional desats & apneic periods  GCS 8  PCO 2 95 & pH 7.10 on VBG How do you treat this patient’s toxidrome?

6. Case #1  IV naloxone can precipitate a life-threatening withdrawal reaction  IV access can be difficult  Needles convey a risk of exposure to blood bourne pathogens

7. Case #1  Nebulised Naloxone!

8. Case #1  Nebulised Naloxone, cont’d…  Weber et al, Pre-hospital Emergency Care 16: 2012 -105 patients 22%, complete response 59%, partial response 19%, no response

9. Case #1  Nebulised Naloxone, cont’d…  How many doses are required?  Weber et al, 10% of patients required IV rescue dose  Baumann et al, 40% of patients required > 1 dose

10. Case #1  Nebulised Naloxone, cont’d…  My Experience & Advice  2mg of naloxone & 3cc of normal saline  “Stimulate” patient to breathe  Allow patients to self titrate their medication  How much Naloxone do you have in your department?

11. Case #2  28 year old male.  MVC. Ejected from vehicle at 120 km/h  Arrives intubated, doesn’t move extremities  HR 65, BP 89/60

12. Case #2

14.  Guide Wire J-Tip Orientation:  Tripathi et al, Anesthesia & Analgesia 2005; 100: 21-4

15. Case #2  Guide Wire J-Tip Orientation:

16. Case #2  The “Ambesh” Maneuver:  Manual occlusion of the ipsilateral Internal Jugular vein at the supraclavicular fossa.

17. Case #2

19. Case #3  18 year old male, right sided thoracic stab wound.  Deviated trachea, shallow resps, absent right breath sounds.

20. Case #3  Are you in the right place? Ferrie et al, Emerg Med J 2005;22:788–789

21. Case #3

22.  Is your patient too thick or your needle too short?

23. Case #3

24.  Is your patient too thick or your needle too short?  Zengerink et al 2008 Retrospective review of Chest CTs for blunt trauma Measured distance from skin to pleura at 2 nd ICS, MCL Mean CWT = 3.51cm right, 3.5cm left 19% of men had CWT > 4.5cm 35.4% of women had CWT > 4.5cm

25. Case #3  Is there a preferred alternate site of Needle Thoracostomy?  Inaba et al, 2011  Cadaver study. Needle thoracostomy at 2 different sites  Does a lateral approach lead to more successful placement?

26. Case #3 2 nd ICS MCL 5 th ICS MAL

27. Case #3  Is there a preferred alternate site of Needle Thoracostomy?  Inaba et al, 2012 Step-wise increase in CWT across all BMI quartiles @ each location CWT was less at 5 th ICS 42.5% of patients had CWT >4.5CM @ MCL, & 16.7% @ 5 th ICS

28. Case #4  56 year old obese male, collapsed and seized at a shopping mall food court.  Arrives in your ED GCS 3, sonorous resps and vomiting  Despite your best efforts, this patient desats before you can pass the ET tube

29. Case #4

34.  High Flow Apneic Oxygenation  How Does it Work?  Complications?

35. Case #4

36. Questions?