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The 4 Triads of ACLS Survey

12/7/2023

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The 4 Triads of ACLS Survey

The following 4 triads of ACLS survey is a structured approach aimed at rapid and prioritized patient assessment and intervention during emergencies.

A, B, C.
O2, I-V, monitors.
Blood pressure, pulse rate, and respiratory rate.
History, physical, and labs.

1. A, B, C
A: assess airway:

Establish and maintain a clear airway.
Use the least invasive method necessary, such as a nasopharyngeal airway or a supraglottic airway device.

B: assess breathing:

Assess breathing patterns and oxygenation levels.
Check SpO2.
Check End-tidal CO2 level to verify endotracheal tube position.
Avoid over-ventilation during manual bag-valve-mask ventilation.

C: assess circulation:

Check pulse, blood pressure, capillary refilling time, and skin color.

D: defibrillate if indicated:

If the patient is pulseless, immediate defibrillate if VF or VT is found on the ECG monitor.
A traditional defibrillator or an AED can be used for this purpose.

2. O2, I-V, monitors

Give oxygen via cannula or mask to maintain SpO2 at 94% or above.
Establish I-V or I-O access.
Obtain blood tests.
Match blood type if indicated.
Give fluids or medications.
Give blood products if indicated.
On monitors, include defibrillator, pulse oximeter, BP monitor, and waveform capnography.

3. Vital Signs

Check blood pressure, pulse rate, and respiratory rate regularly
Check additional vital signs if necessary, include body temperature, SpO2, fingerstick sugar, and GCS.
Remember to re-evaluate ABC if vital signs suddenly deteriorate.

4. Differential diagnosis

AMPLE is a mnemonic used to guide focused history-taking.
A = Allergies.
M = Medications.
P = Past medical history.
L = Last meal.
E = Events leading up to the present situation.
Physical examination and laboratory tests are also crucial for accurate differential diagnosis.

Conclusion

The ACLS survey is a systematic and structured approach crucial in managing medical emergencies.
By adhering to this 4-step approach, healthcare providers can provide swift intervention, significantly enhancing the chances of positive patient outcomes in critical situations.

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How to Remove IO Needle (EZ-IO)

12/7/2023

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How to Remove IO Needle (EZ-IO)

To remove an IO needle inserted using the EZ-IO device, follow the following steps:

Step 1. Disconnect any infusions connected to the IO catheter.
Step 2. Remove the stabilizer and adhesive.
Step 3. Attach a 10 mL sterile syringe with a standard luer-lock to the catheter hub.
Step 4. To remove the catheter, grasp the syringe and catheter hub, and gently rotate the catheter clockwise while pulling straight back. Avoid rocking the catheter on removal.
Step 5. Dispose of the catheter and syringe in an approved sharps container and then apply dressing to the skin.

Conclusion

To remove an I-O needle inserted using the EZ-IO device, grasp the syringe and catheter hub, and gently rotate the catheter clockwise while pulling straight back
Avoid rocking the catheter on removal. Be aware that, if the syringe is twisted counter-clockwise, it will unscrew from the short hub, which can be difficult to grasp.
Please note that these steps are a general guide for removing an IO needle using the EZ-IO device.

Remove intraosseous needles as soon as another stable route of vascular access is established.

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Bronchiolitis

12/7/2023

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Bronchiolitis

Pathophysiology of bronchiolitis

Viral infections, especially Respiratory Syncytial Virus (RSV), induce inflammation in the lower respiratory tract, resulting in edema, necrosis of epithelial cells, bronchospasm, and increased mucus production in the bronchioles.
This inflammation heightens airway resistance, leading to air trapping, atelectasis, and hyperinflation. Additionally, nasal obstruction arises due to mucus production.

Clinical features of bronchiolitis

Common symptoms include rhinorrhea, tachypnea, wheezing, coughing, accessory muscle use, nasal flaring, and fever.
Wheezing and crackles are heard on chest examination.
These symptoms may last 7 to 21 days, peaking between days 3 and 5.
Note that, some infants may develop severe disease with apnea, leading to hypoxia and requiring endotracheal intubation.

Diagnosis of bronchiolitis

Clinical diagnosis is suspected by history of typical symptoms in chuldren under 2 years of age.
Though rapid viral antigen tests may be helpful, routine blood tests and routine radiographs are not necessary.
Monitoring oxygen saturation with pulse oximetry is important for severity assessment.

Treatment of bronchiolitis

Some important outpatient management include: Saline instillation into nares followed by suctioning, frequent small feeds, and hand hygiene.
Bronchodilators are not suggested for routine use. Bronchodilators may improve symptoms briefly but do not shorten the days of symptoms, admission rates or length of stay.
Inhaled epinephrine and corticosteroids may help when used in combination in severe cases. Hypertonic Saline has no proven benefits in routine use.
Oxygen should be given to keep SpO2 above 90%. Noninvasive ventilatory support may help avoid intubation and mechanical ventilation.

Disposition of bronchiolitis

Advise caregivers to promptly seek reevaluation if any of these symptoms emerge: respiratory distress signs such as tachypnea, observed retractions, and feeding difficulties.
Demonstrate correct nasal suctioning methods to caregivers. Indications for admission include: Prematurity, persistent tachypnea, dehydration, witnessed apnea, and oxygen desaturation with SpO2 below 90%.
Remember to educate parents about the potential persistence of symptoms for up to 3 weeks to prevent unnecessary returns to the emergency department due to persisting mild symptoms.

Take home message

Bronchiolitis is a common viral illness in infants, especially during winter months. It’s symptoms typically resolves on its own but can last for up to 3 weeks.
Treatment focuses on hydration and symptom management rather than the infection itself.
High risk infants include babies less than 2 months of age and infants born prematurely, who may experience recurrent apneic spells and may require hospital admission.
Palivizumab may prevent bronchiolitis caused by RSV in extremely vulnerable patients as suggested by the American Academy of Pediatrics.

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Visual Diagnosis Part 7

12/7/2023

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Visual Diagnosis Part 7

Intercalary bones are triangular ossifications found in the anterior annular fibers of an intervertebral disc and are believed to be degenerative in etiology. Do not misinterpret intercalary bones as bony fractures.
Glottic impersonation occurred as a result of a forceful laryngoscopic maneuver. The vocal cords and glottic opening are revealed when the laryngoscope is pulled back a little. Glottic impersonation refers to the misinterpretation of the glottic opening during intubation or laryngoscopy. This can occur due to anatomical distortions from a forceful laryngoscopic maneuver or neoplasms.
Prostate cancer with metastases to pelvic bones and the lumbar spine. Sclerotic bone metastases are often associated with prostate carcinoma. "Ivory vertebra" refers to a radiographic finding where affected vertebrae have sclerotic bone metastases associated with prostate cancer.
Herpangina primarily affects children, adolescents, and young adults. It is characterized by small ulcerative or vesicular lesions in the posterior oropharynx and is highly contagious. It is caused by enteroviruses, with the Coxsackie B virus serotype being the most common. The virus is spread through respiratory droplets, saliva, directly touching fluid from a sore, or through stools. The symptoms of herpangina include a high fever and blister-like sores in the mouth and throat, which can be painful. The illness is similar to hand, foot, and mouth disease and is most common in the summer and fall months.
Greenish discoloration of plasma can be caused by: Pregnancy, birth control pills, rheumatoid arthritis, drugs such as sulfonamides (which cause sulfhemoglobinemia), sepsis due to Pseudomonas, high ceruloplasmin levels, and intravenous methylene blue.
Necrotizing enterocolitis (NEC). NEC primarily affects premature or newborn babies. NEC is characterized by inflammation of the intestine, leading to bacterial invasion, cellular damage, and necrosis of the colon and intestine. Pneumatosis intestinalis is a condition where gas accumulates within the intestinal wall, as shown in the KUB radiograph. The mortality rate of N-E-C can be as high as 50%. In some cases, air can also be seen in the portal venous system of the liver.

Bladder calculi or bladder stones. Bladder stones can be primary, secondary, or migratory. Primary stones occur in the absence of other urinary tract abnormality. Secondary stones are associated with abnormal bladder or foreign material such as urinary catheters. Migratory stones are renal calculi migrated down into the bladder.

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Effective Communication

12/7/2023

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How to Communicate Effectively in Emergencies:

Be clear and concise: Use simple language and avoid medical jargon to ensure clear understanding during high-stress situations.
Use closed-loop communication: Confirm that your message has been received and understood by asking for feedback or repeating important information.
Prioritize information: Share the most critical details first to ensure immediate action can be taken.
Maintain a calm demeanor: Stay composed and avoid showing panic or frustration, as it can affect the overall communication process.
Use non-verbal communication: In noisy or chaotic environments, utilize hand gestures, visual cues, or written notes to enhance communication.
Establish a team communication plan: Designate roles and responsibilities for communication within the team to avoid confusion and streamline information flow.
Utilize effective listening skills: Actively listen to others and provide undivided attention, allowing for accurate comprehension and response.
Repeat and clarify: Repeat important instructions or information to ensure it is fully understood by all team members.
Adapt communication style: Tailor your communication approach based on the individual's level of understanding, cultural background, or language barriers.
Use closed-ended questions: When gathering information, ask specific questions that require concise answers to facilitate quick decision-making.
Document important information: Maintain accurate and detailed records of communication exchanges, including patient updates and treatment plans.
Anticipate and address communication challenges: Identify potential barriers, such as noisy environments or language barriers, and proactively find solutions to overcome them.
Communicate with empathy: Show compassion and understanding towards patients, their families, and fellow healthcare professionals to build trust and rapport.
Use technology effectively: Utilize communication tools like mobile devices, radios, or telemedicine platforms to enhance real-time information sharing.

Practice effective teamwork: Foster a collaborative environment where open communication is encouraged, allowing for efficient information exchange and decision-making.

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The 4 Triads of ACLS Survey

How to Remove IO Needle (EZ-IO)

Bronchiolitis

Visual Diagnosis Part 7

Effective Communication

AuthorTwitter: @jackcfchong[email protected]

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Twitter: @jackcfchong
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