Remember the ‘Golden Numbers’ - 75, 100, 150, 200.
Atrial Flutter 2:1 block can present as broad complex tachycardia at rate 150 if bundle branch block exists.
Be wary of rates that are perfectly regular with rates of 75, 100, 150, 200 - they may represent atrial flutter with a 4:1 or 3:1, 2:1 or 3:2 block.
Look for the p waves embedded in t waves.
Also remember Brugada criteria for VT (92-96% sensitive):
If no RS complex in V leads —— diagnose VT
If R to S nadir time is > 100ms ——— diagnose VT
If av dissociation ———————diagnose VT
If V1 and V6 morphology suggest VT - diagnose VT
If none of above ——— diagnose SVT with aberrancy.
Guillain Barre in ED - acute inflammatory demyelinating polyneuropathy - ascending motor paresis with lower motor neurone features with some dyautonomia and cranial nerve abn - don’t forget to check FVC and FIP.
GBS presents occasionally to ED as paediatric or adult weakness. Key components of the clinical picture include
-varying degrees of lower limb weakness ( sometimes presenting as new onset ‘cannot walk’), LMN signs in ascending pattern
-usually mostly motor, but some sensory deficit
-decreased or equivocal reflexes
- dysautonomia (fluctuations in hr bp diaphoresis )
- respiratory failure with chest wall muscle weakness
Remember to check FVC (<15L/kg) and FIP (<-25 cmh2o) as indicators for intubation and mechanical ventilation.
Avoid suxamethonium and optimize vitals with short acting vasoactive agents ( esmolol if hypertensive, noradrenaline if hypotensive) prior to RSI.
Abnormal Uterine Bleeding - causes classified by PALM COEIN - Polyp - Adenomyosis- Leiomyoma - Malignancy - Coagulation - Ovulatory - Endometrial - Iatrogenic - not classified
ACOG 2011 updated their approach to classification of abnormal uterine bleeding in non pregnant patients. PALM - structural vs COEIN - nonstructural.
Myasthenic patients may present to ED with shortness of breath without obvious signs of distress ( because resp accessory muscles are weak and fatiguing !)
Common precipitants are infections and antibiotics or other meds - sometimes disease course
Measure the negative inspiratory pressure or the FVC - if <25 cm h2o or 15L/kg - discuss with icu and neurology need for:
NIV or CVM
Plasmapharesis or Steroids
Physostigmine is NOT used for acute myasthenia
Management in ED - know the key consultant issues, goals of management and remember DRS ABCDE. When considering RSI - think : HHAARRMMS and the P’s. When ventilating - use a ppv, lung protective or obstructive strategy.
Evidence deficit for burns formulas and fluid type - ANZBA recommends parklands formula in adults using Hartmanns
4ml/kg/tbsa has been the standard formula used in most ed settings in Australia and ANZBA has further endorsed this for adults.
Most Paediatric centres in Australia actually suggest 2 or 3 ml/kg / tbsa - which is a modified formula
Hartmanns is the suggested fluid
Remember to provide maintenance in children split between
NGT 10 ml/ hr as feeds or ors
Iv Hartmanns 5% dextrose.
Remember to suntract any bolus NS from parklands.
If shock - NS 10-20ml/kg
Modified parklands - 2 or 3 ml/kg/tbsa Hartmanns
( sorts our deficit)
10ml/hr NGT ors or milk
Iv Hartmanns 5% dextrose.
Assess for losses
Check out :
Use a Lund and browder chart in children and Wallace’s rule of nines in adults.
The best clinical indicator of inhalational burn is stridor - if absent - facial or lip signs are inaccurate at predicting supraglottic or glottic injury. Use awake oral anaesthetic laryngoscopy with ketamine dissociation to exclude inhalational injury with fibreoptic or video laryngoscopy.
The ED PHYSICIAN considerations are the difficulty excluding airway inhalational burn, overestimation of TBSA and the evidence deficit for what formula and type of fluid to use for resuscitation.