Precipitous delivery in the ED

A simplified approach to precipitous delivery in the emergency department

Case

You are chatting with your triage nurses on a slow night shift when a car pulls up to the front doors. A 34 year old woman G5P4 at 39 weeks gestation is wheeled up to triage by a slightly panicked appearing boyfriend. Her waters broke in the car on the way in and she feels the need to push. A quick exam after you get her through the doors reveals that she is crowning.

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Laryngospasm

A simplified approach to the management of laryngospasm in the emergency department

Case

A feisty 3 year old tripped, cut her lip, and is now politely refusing your colleague’s attempts at suturing. You hear these polite refusals from across the department, and wander over to offer your help with a procedural sedation. After moving to an appropriate room, going through the pre-sedation checklists, and tracking down all the folks that are required to be present, you give a dose of ketamine (1mg/kg IV). Just as you are about to entertain the room with your latest cheesy joke, you hear a loud squeaking. You glance at the patient and recognize significant respiratory muscle contraction and stridor. A quick glance at the monitor shows a flat CO2 tracing. Oh no, laryngospasm…

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Tet Spell

A simplified approach to the assessment and management of children the cyanotic (TET) spells in the emergency department

Case

A 2 month old boy is brought into the resus room of your community hospital looking completely blue. The mother rather anxiously states that they have been followed at the large pediatric hospital for Tetralogy of Fallot and are awaiting elective repair. They came to your hospital because it was the closest to the relatives they were visiting for Christmas. They were warned about “spells” but can’t remember what to do. The child appears severely cyanotic, is crying loudly, and the nurses are unable to get a saturation reading for you. Continue reading “Tet Spell”

Welcome

Welcome to First10EM, a FOAMed project where I plan to contemplate the necessary actions of the first 10 minutes in the resuscitation room for patients that I might encounter in the future. This is a site about resuscitation. It is about what to do when the sickest patients are wheeled through your door and it is about how to prepare yourself before you ever see those patients.

“First 10” refers to the first ten minutes in the resuscitation room, when immediate action is necessary and information is generally lacking. In most of medicine, I am a strong believer in doing less; in the mantra “don’t just do something, stand there”. The first ten minutes in the resuscitation bay are an exception. They are a time for action rather than contemplation. You must know what you are going to do, how you are going to do it, and why it is being done well before the patient arrives.

My goal is to create a collection of the scenarios that need to be managed instantly. Things that we need to know cold, because we will never have time to look them up.

For me, this is also a site about simulation. Not the kind that occurs with a group around a high tech mannequin, but the kind that you can do anywhere and everywhere. The kind that occurs within what I have heard Cliff Reid (@cliffreid) refer to as “the most high fidelity simulator in the universe”: the human brain.

The idea is to visualize the case – to truly simulate it in your brain – to the extent that you can actually picture your own resus room. So that if your third option for managing a difficult airway requires a scalpel and a bougie, you can picture exactly which drawer those will be in, and you can see your hand moving the knife across the neck, so that those actions are automatic if and when they are ever required.

I know that to some extent most of us already do this simulation, driven by the mild anxiety and slightly elevated levels of endogenous adrenaline that go along with being an emergency doctor. However, aside from promoting this ‘cerebral simulation’ I hope this site will also act as a reminder of rare emergencies that aren’t as frequently discussed and therefore probably aren’t frequently simulated. I have visualized myself performing a cricothyrotomy and a perimortem c-section thousands of times. I was driven to create this site when I realized that there were other scenarios I just wasn’t preparing for. I had never truly visualized the steps I would take when faced with a TET spell or a breech delivery when working, as I sometimes do, far away from the closest obstetrician.

What this project is supposed to represent is my current best approach, based on the resources available at my community hospital and my best read of the literature. The goal is to think the cases through, not to be sure I am correct. I hope to uncover shortcomings in my current knowledge and slowly refine my approach to resuscitation. If through discussion on this site, people can point out my flaws and improve my practice, all the better.

What this site is not meant to be is a place with a lot of answers. I will freely admit that I am not an expert in resuscitation. I am a community doctor still gaining experience. If you want solid answers, check in the with masters: Scott Weingart at EMCrit, Cliff Reid at Resus.me, all the folks at the RAGE podcast, the crew of Life In The Fast Lane … I shouldn’t have started naming names because I can’t possibly list them all, but you get the idea. Go to them for answers, what I hope to do is raise a few interesting questions.

So, with that in mind, I happily but anxiously leap into the waters of FOAMed…