Month: April 2016

Circulation (Shock)

Today is episode C, the final episode in our 3 part podcast series on the approach to a crashing patient. In previous episodes we covered AIRWAY: how the first thing we need to do is suction and move the posterior portion of the patient’s tongue. We covered BREATHING: how we need to fix hypoxia by increasing FiO2 and adding PEEP. And today we are covering CIRCULATION.

With circulation, it all comes down to tank, clogged pipes, broken pipes, and pump. Which is a fancy way of saying… We fix all of the different types of SHOCK. So pay close attention, because the treatment of shock is a hugely important topic in Emergency Medicine. It is a topic that you need to master if you want to pass your shelf and do well on your SLOE.

Breathing

Today is episode B in a series about our approach to the crashing patient. As we discussed in the previous episode, at some point during your clerkship, you will have a patient that starts dying right in front of your eyes. And it will be very scary! In Emergency Medicine, we fall back onto the “A-B-Cs” whenever this happens. We fall back onto an algorithm that lets us take control of virtually any situation in less than 60 seconds.

In this episode, we cover B-Breathing. In medical school, we learned that breathing equals both oxygenation and ventilation. However, between the two of these, oxygenation is BY FAR the most important in the acute setting. Hypoxia kills patients immediately, so you need to fix hypoxia immediately. As we will discuss in this episode, there are only two ways to do this. You either add FiO2, or you add PEEP.

Airway

During your clerkship, you will be encountering sick patients. This is obvious. However, I promise that at least one of these patients will catch you VERY off guard. It usually goes like this, you are walking into a room, ready to take a history from (what sounded like) a straight-forward patient. But as soon as you open that door… WHAM! You see an unconscious, hypoxic, hypotensive patient. Maybe they are simultaneously vomiting and pooping blood. Maybe they are limp, blue, and not breathing. Maybe they seize, fall on the floor, and smash their head. Your heart rate speeds up. A lump crawls into your throat. What do you do?

Easy. You start with the A-B-Cs.

In this episode, we cover A (Airway). And here is a hint, the algorithm does NOT start with intubation. Will you be able to intubate 5 minutes from now? Maybe. If the patient lives that long. But you need to act now. So what I plan on teaching you is an algorithm that allows you to take control of literally ANY situation in 60 seconds or less. I plan on giving you a FEAR algorithm. A plan for when soft, brown, mushy stool flies through the proverbial fan and sloshes all over your patient’s hemodynamic status.

Epistaxis

If you listened to the introduction episode, you heard my story about the patient with a bleeding nose. I had NO IDEA what to do. It was embarrassing. And that specific situation is what inspired the creation of this episode. Nosebleeds can be scary! You will probably have a patient with this during your clerkship, and the approach requires a completely different mindset than when we just articulate the differential diagnosis for a Core 4 medical complaint. Epistaxis requires a plan with a series of interventions as opposed to labs and imaging, and it WILL throw you off balance if you aren’t prepared.

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