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Date: October 17th , 2018

Reference #1: Aycock, Westafer et al. Acute Kidney Injury After Computed Tomography: A Meta-analysis. Ann Emerg Med 2018 (CRD42017056195)

Reference #2: Weisbord SD, Gallagher M, Jneid H, et al; PRESERVE Trial Group. Outcomes after Angiography with Sodium Bicarbonate and Acetylcysteine. NEJM 2018 (ClinicalTrials.gov NCT01467466.)

Guest Skeptic: Dr. Lauren Westafer is a board certified emergency physician at Baystate Medical Center and instructor in the Department of Emergency Medicine at the University of Massachusetts Medical School. She is author of the blog, The Short Coat, and cofounder of the emergency medicine podcast, FOAMcast. Lauren is currently funded by an NHLBI K12 grant (1K12HL138049-01) studying the implementation of evidence-based diagnosis of pulmonary embolism in the emergency department.

Case: A 64-year-old woman with type-2 diabetes. She presents to the emergency department with chest pain and some shortness of breath. The acute coronary syndrome work-up is negative but she is Well’s high and needs a CTPA to rule-out a pulmonary embolism. Her GFR is 50 and you are wondering if the contrast needed for the CT will cause an acute kidney injury (AKI) and if so, can you do anything to mitigate causing an AKI?

Background: There has been a huge increase in the number of CT scans performed with more than 75 million CT scans performed in the US in 2013. Some scans require intravenous contrast (CTPA and CTCA) while in other cases it may improve image quality.

There has been a lot of ink spilled over contrast-induced nephropathy (CIN). It came out of case reports and non-controlled studies. Historically the CTs were done with high osmolar contrast material and these non-controlled studies showed a rise in AKI. However, we now use iso-osmolar or low osmolar contrast and we are not seeing kidneys die as a result.

Multiple observational studies have been published demonstrating that AKI in the modern era does not exist. Part of the difficulty with this topic is the inconsistent definition of contrast-induced nephropathy. A common definition is an increase in creatinine level by 25% or an absolute increase of 0.3 to 0.5 mg/dL within 3 days.

These are all disease-oriented outcomes (change in laboratory values) not patient-oriented outcomes like death or need for dialysis.

Clinical Question #1: Is CT contrast associated with acute kidney injury?

Reference: Aycock, Westafer et al. Acute Kidney Injury After Computed Tomography: A Meta-analysis. Ann Emerg Med 2018 (CRD42017056195)

* Population: Adult humans

* Exclusions: Pediatrics, non-human studies, studies of contrast enhanced procedures (ex: coronary angiography), interventional studies, case reports, review articles, clinical guidelines, other meta-analyses

* Intervention: Contrast enhanced CT scans

* Comparison: Noncontrast CT scan

* Outcome:

* Primary Outcome: Incidence of acute kidney injury

* Secondary Outcomes: Mortality or need for renal replacement therapy

Authors’ Conclusions:“We found no significant differences in our principal study outcomes between patients receiving contrast-enhanced CT versus those receiving noncontrast CT. Given similar frequencies of acute kidney injury in patients receiving noncontrast CT, other patient- and illness-level factors, rather than the use of contrast material,

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Date: October 10th , 2018

Reference: Karlow et al. A Systematic Review And Meta-Analysis of Ketamine as an Alternative to Opioids for Acute Pain in the Emergency Department. AEM Oct 2018.

Guest Skeptic: Dr. Corey Heitz is an emergency physician in Roanoke, Virginia. He is also the CME Editor for Academic Emergency Medicine.

Case: You are caring for a 38-year-old male (Larry) who presented to the emergency department with lower back pain. During your evaluation, he tells you he doesn’t want any narcotic pain medication. You wonder if there are alternative options, and a colleague reminds you that ketamine has recently gained a lot of exposure as a possible alternative.

Background: The amelioration of pain and suffering should be one of the top priorities of emergency physicians.  In 2001, JACHO made pain the 5th vital sign to address the issue of oligoanalgesia, which unfortunately created many problems.

Opiates became a very common treatment for acute pain in the ED setting after JACHO and the introduction of new and powerful opioids like oxycodone.

However, in recent years, an increased desire for alternatives has been prompted in an attempt to reduce opiate usage. The pendulum is swinging to opiophobia. This can leave the patient left in the middle with ineffective pain management.

One alternative or adjunct to limit the use of opioids in the ED is low dose ketamine (LDK). Several studies have been performed evaluating low dose ketamine (LDK) for acute pain, with a variety of methodological designs, time endpoints, and doses.

We have covered some of those papers and watched the literature develop over the years on the SGEM.

* SGEM#111: Comfortably Numb – Low dose Ketamine as Adjunct for ED Pain Control

SGEM Bottom Line: High-quality published evidence to support the use of sub dissociative-dose ketamine to quickly reduce acute pain in emergency department settings is lacking, but lower quality studies inconsistently demonstrate effectiveness with uniformly low risk of adverse effects.

* SGEM#130: Low Dose Ketamine for Acute Pain Control in the Emergency Department (reviewed two ketamine papers)

SGEM Bottom Line: For patients who have a contraindication to opioids such as allergy or hypotension, sub dissociative ketamine would be a reasonable option to consider for treating acute pain.

SGEM Bottom Line: While further validation in other settings is needed, this study suggests ketamine as a relatively safe option for patients who do not achieve analgesia with high doses of morphine or are unable to tolerate them.

* SGEM#198: Better Slow Down – Push vs. Short Infusion of Low Dose Ketamine for Pain in the Emergency Department

SGEM Bottom Line: Slowing down the rate of low-dose IV ketamine infusion to 15 minutes significantly reduces rates of the feeling of unreality and sedation with no difference in analgesic efficacy when compared to IV push over 3 – 5 minutes. 

Clinical Question: Is ketamine, at a dose of <0.5mg/kg, as effective as opiates for the treatment of acute pain in the emergency department?

Reference: Karlow et al. A Systematic Review And Meta-Analysis of Ketamine as an Alternative to Opioids for Acute Pain in the Emergency Department. AEM Oct 2018.

* Population: Randomized control trials (RCTs) wit...

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Date: October 5th , 2018

Reference: Stiell et al. A Multicenter Program to Implement the Canadian C-Spine Rule by Emergency Department Triage Nurses. Annals of EM Oct 2018

Guest Skeptic: Alison Armstrong is an Emergency Department Nurse, TNCC Course Director, Trauma Program Coordinator and Canadian C-Spine Rule Nurse Champion.

Case: There are two case scenarios this week to try and capture the two common ways patients present to the triage nurse.

* Case 1: A 51-year-old male patient presents to triage in a collar on a back-board via EMS following a rear-end motor vehicle collision (MVC) at a stop light. He was a belted driver with no past medical history and GCS 15. The driver of the car that hit him was texting and did not appear to slow before striking the rear of the patient’s car at about 50 km/hr. The patient complains of left shoulder and neck pain.

* Case 2: A 45-year-old female presents to triage at 20:30 walking stating that she fell from a chair this morning. She went to work all day as she thought she was unhurt initially, but pain has started to set in so she stopped by the emergency department on the way home complaining of right wrist and neck pain and stiffness all over. She is worried she may have a serious injury to her neck. 

Background: Clearing the c-spines is a regular activity in the emergency department (ED). This can be done clinically using the Canadian C-Spine Rules/Tools or with imaging. The vast majority of these patients (>99%) do not  have a fractured cervical spine diagnosed.

Blunt trauma patients transported via EMS often arrive on a backboard, c-collar and head restraints. They remain this way often complaining to the nurse until they can be assessed by a physician and have their c-spine cleared.

There are protocols to get blunt trauma patients off spine boards urgently. However, they still can remain in c-spine precautions for a long time waiting to be assessed. This adds to patient discomfort, occupies valuable acute ED space and can contribute to crowding.

The Canadian C-Spine Rule (CCR) is a clinical decision instrument developed to allow clinicians to clear the c-spine without imaging (1). This instrument has been validated to be safe and decrease use of diagnostic imaging (2,3).

Canadian C-Spine Rule (CCR)

The CCR applies to alert (GCS=15) and stable trauma patients where cervical spine injury is a concern

* Dangerous Mechanism

* Fall from elevation>=3 feet/ 5 stairs

* Axial load to head (diving)

* MVC high speed (>100km/hr), rollover, ejection

* Motorized recreational vehicle

* Bicycle collision

Clinical Question: Can emergency department triage nurses apply the Canadian C-Spine Rule to adult blunt trauma patients and safely clear the c-spine?

Reference: Stiell et al. A Multicenter Program to Implement the Canadian C-Spine Rule by Emergency Department Triage Nurses. Annals of EM Oct 2018

* Population: Alert adults presenting to the ED ambulatory or by EMS with acute blunt trauma occurring within the previous 48 hours with posterior neck pain and were in stable condition. Alert and stable was defined as a Glasgow Coma Scale (GSC) score of 15 with normal vital signs.

* Exclusions: Age less than 16 years, penetrating trauma, acute paralysis, or known vertebral disease

* Intervention:

* Phase 1 (Certification): All ED nurses who performed triage activities had didactic training and then had to demonstrate competence by accurately assessing ten patients before being certified.

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Date: September 21st, 2018

Reference: Kawano et al. Intraosseous Vascular Access Is Associated With Lower Survival and Neurologic Recovery Among Patients With Out-of-Hospital Cardiac Arrest. Annals of EM May 2018

Guest Skeptic: Andrew Merelman is a critical care paramedic and first year medical student at Rocky Vista University in Colorado. His primary interests are resuscitation, prehospital critical care, airway management, and point-of-care ultrasound.

Case: A 46-year-old man has a cardiac arrest at home, witnessed by family. Bystander CPR is initiated prior to EMS arrival. EMS arrives on scene and initiates high quality basic life support (BLS). One defibrillation for ventricular fibrillation (VF) is provided but the patient remains in VF. As part of their protocol, they attempt vascular access to administer epinephrine and an antidysrhythmic. They wonder whether it would be better to attempt a peripheral intravenous (IV) line or intraosseous access first?

Background: Cardiac arrest care has evolved drastically over the past couple of decades, but not in the way many may have expected. We now know that an emphasis on the basics (high quality chest compressions and defibrillation) are the most important aspects of resuscitation. More advanced skills such as airway management, vascular access, and cardiac medications are being de-emphasized.

It was the classic OPALS paper covered on SGEM#64 by the Legend of Emergency Medicine Dr. Ian Stiell that demonstrated no advantage to ACLS vs. BLS for out-of-hospital cardiac arrest (OHCA).

There have been other SGEM episodes that question the efficacy of various interventions:

* Man vs. mechanical CPR for OHCA (SGEM#136)

* ACLS for OHCA (SGEM#189)

* Not Stayin’ Alive More Often with Amiodarone or Lidocaine (SGEM#162)

* Remote ischemic conditioning for OHCA (SGEM#116)

* Pre-hospital therapeutic hypothermia (SGEM#21, SGEM#54, SGEM#82 and SGEM#183)

The resuscitation science community has been struggling to find advanced interventions that can show a benefit in mortality and, most importantly survival with good neurological outcome.

Intraosseous access has become a mainstay of cardiac arrest care due to its speed and reliability. However, no randomized trial has compared intravenous access to intraosseous access with a primary outcome of good neurologic function.

Clinical Question: Is intraosseous vascular access in the pre-hospital setting for OHCA associated with better neurologic outcomes compared to intravenous vascular access?

Reference: Kawano et al.Intraosseous Vascular Access Is Associated With Lower Survival and Neurologic Recovery Among Patients With Out-of-Hospital Cardiac Arrest. Annals of EM May 2018

* Population: Out-of-hospital, non-traumatic, adult cardiac arrest patients

* Excluded: Unsuccessful attempt or more than one access site. Patients were also excluded if incarcerated or pregnant...

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Date: September 17th, 2018

Reference: Meltzer, A. et al. Effect of Tamsulosin on Passage of Symptomatic Ureteral Stones: A Randomized Clinical Trial. JAMA Internal Med, 2018.

Guest Skeptics: Dr. Tony Seupaul, Professor and Chair, University of Arkansas for Medical Sciences Department of Emergency Medicine. Dr. Daniel Holleyman, Chief Resident at University of Arkansas for Medical Sciences Emergency Medicine Residency.

Case: A 51-year-old man presents to the emergency department (ED) with five-hour history of acute onset left flank pain.  The pain comes in waves, radiates into his left groin and is associated with nausea and vomiting.  He noticed darkening of his urine, but does not have dysuria, fever, testicular pain, or penile discharge.

You work him up and the urine analysis shows large blood, negative nitrites, negative bacteria.  CT abdomen/pelvis without contrast is done which identifies a 7mm radiopaque stone in the left distal ureter.  The patient receives 15mg ketorolac IV (SGEM#175) because you know there is a ceiling to the analgesic effect of non-steroidal anti-inflammatory drugs (NSAIDs). His pain improves significantly, and he is ready for discharge. He is given a referral to Urology for follow up of his ureteral stone, a prescription for oral antiemetics, and advised to take over-the-counter (OTC) NSAIDs. He asks if there is anything he could do or take to help the stone pass faster?

Background: We have covered renal colic many times on the SGEM. This has included the medical expulsive therapy using alpha blockers, lidocaine for pain control, pushing IV fluids or diuretics to pass stones, ultrasound vs. CT scans for diagnosis, and even acupuncture vs. morphine for renal colic pain.

* SGEM#4: Getting Un-Stoned (Renal Colic and Alpha Blockers)

* SGEM#32: Stone Me (Fluids and Diuretics for Renal Colic)

* SGEM#71: Like a Rolling Kidney Stone

* SGEM#97: Hippy Hippy Shake – Ultrasound Vs. CT Scan for Diagnosing Renal Colic

* SGEM#154: Here I Go Again, Kidney Stone

* SGEM#202: Lidocaine for Renal Colic?

* SGEM#220: Acupuncture Morphine for Renal Colic

The SGEM bottom lines on the management of renal colic from those previous episodes were as follows:

* Expulsive therapy is unnecessary for ureteric stones < 5mm.

* You don’t need to push fluids (oral/IV) or use diuretics to pass kidney stones.

* There is some weak evidence that Tamsulosin MAY help passage of larger stones (5 to 10 mm).

* Bedside emergency department ultrasound is safe and has several advantages over CT for the diagnosis of kidney stones.

* Lidocaine cannot be recommended for the treatment of renal colic at this time.

* The evidence does not support the claim that acupuncture is superior to morphine for renal colic.

Clinical Question: Does initiation of Tamsulosin at the time of diagnosis in ED patients with symptomatic ureteral stones less than 9mm increase the rates of stone passage in the following 28 days?

Reference: Meltzer, A. et al.

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Date: September 10th, 2018

Reference: Gurley et al. Comparison of Emergency Medicine Malpractice Cases Involving Residents to Non-Resident Cases. AEM September 2018

Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the Director of Simulation Education at Markham Stouffville Hospital in Ontario. He is the creator of the excellent #FOAMed project called First10EM.com

Case: You are giving an introductory lecture on evidence-based medicine to the incoming class of residents, and after you finish you notice some excited chatter at the back of the room. Thinking that you have found some EBM keeners/gunners, you wander over to join the discussion, but find yourself in a heated discussion. One of the senior residents was recently named in a lawsuit, and the junior residents are worried. How likely are they to be sued? What can they do to prevent such a harrowing event? The residents turn to you, hoping that you can provide some insight on this topic.

Background: Unfortunately, physicians are not perfect. Mistakes are made occasionally, and those mistakes can harm our patients.

Medical care provided by trainees involves some added risks. In an internal medicine setting, problems with handoffs, teamwork, and lack of supervision were identified as issues in trainee malpractice cases.

In Canada, we have a national organization called the Canadian Medical Protective Association (CMPA). The CMPA has approximately 97,000 members representing 95% of Canadian physicians.

There are about 10,000 files opened every year with 38% involving payouts. Only 8% of cases end up in court. There has been a 5% decrease in cases over the last decade.

It is important to note that our medical-legal environment in Canada is much different than in the United States. It is a much more litigious system south of the border. The paper we will be talking about today come out of the US.

Clinical Question: What are some of the key factors in malpractice claims against trainees, and how do those compare to malpractice cases that don’t involve trainees?

Reference: Gurley et al. Comparison of Emergency Medicine Malpractice Cases Involving Residents to Non-Resident Cases. AEM September 2018

* Population: The Comparative Benchmarking System (CBS) database: a large database of malpractice claims covering more than 400 hospitals and more than 165,000 physicians.

* Intervention: Malpractice claims involving trainees (residents) in an emergency department setting over a three-year period from 2009-2012.

* Comparison: Malpractice claims not involving trainees in the same time period.

* Outcomes: Coded information covering a number of domains.

* Average Payment

* Case Severity (low, medium, high or death only)

* Allegation Category (Diagnosis Related, Medical Treatment, Surgical Treatment, Medication Related or other)

* Procedure Involved (yes/no and if yes what procedure)

* Final Diagnosis (ex: cardiac related, orthopedic related, etc)

* Contributing Factors (ex: communication, clinical judgement, documentation, etc)

This is the first SGEMHOP for Season#7 and of course we have the lead author here ready to give her conclusions to the study and Talk Nerdy to us.

Dr. Kiersten Gurley is a Clinical Instructor at Harvard Medical School. She is also an Attending Emergency Physician and Assistant Quality Improvement Director in the Department of Emergency Medicine at Beth Israel Deaconess Medical Center.

Authors’ Conclusions:“There are higher total incurred losses in non-resident cases. There are higher severity scores in resident cases.

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Date: September 5th, 2018

Reference:  Franklin et al. A Randomized Trial of High-Flow Oxygen Therapy in Infants with Bronchiolitis. NEJM March 2018.

Guest Skeptic: Dr. Ben Lawton is a paediatric emergency physician in Brisbane Australia. He divides his time between a tertiary children’s hospital and a community hospital that is busy enough to have its own paediatric emergency department. He is part of the Don’t Forget the Bubbles team.

Case: Elsie is five months old and presents on day two of a bronchiolitic illness. She has taken just under half of her usual feeds so far today and has a respiratory rate of 58 breaths per minute and oxygen saturation of 90% on room air with moderate work of breathing. She is not clinically dehydrated and has a temp of 38.2C with clear rhinorrhea, red ears, a red throat and equal air entry with widespread crackles and wheeze. She was born at term, is immunised and has no significant medical history. Her parents Dave and Tony have driven 20 minutes from home to bring her to the regional hospital where you work. Your hospital has an inpatient paediatric ward but is a 90-minute drive from the nearest children’s hospital with PICU facilities.

Background: We have covered bronchiolitis before on the SGEM#167 with expert Dr. Amy Plint. That episode looked at how bronchiolitis was managed in community hospitals. The bottom line was that there seemed to be a knowledge gap when it comes to managing bronchiolitis in the community setting (previous evidence as suggested a knowledge gap also exists in the academic pediatric hospitals).

Although the vast majority of infants with bronchiolitis can be managed with supportive care at home, due to its high incidence, it is the number one reason for infants to be hospitalized (Njoo et al 2001, Langley et al 2003, Craig et al 2007 and Shay et al 1999).

Since bronchiolitis is a clinical diagnosis, there is no test, including viral testing and radiography, which rules it in or out (Schuh et al 2007). Sadly, despite multiple guidelines (NICE, AAP, CPS), there has also been no “magic bullet” in terms of treatment.

Hypertonic saline has been tried for acute bronchiolitis. A systematic review of this treatment modality was covered on SGEM#157. The bottom line at that time was that the data did not support the routine use of hypertonic saline for mild to moderate acute bronchiolitis.

The American Academy of Pediatrics guideline says that oxygen therapy in infants with saturation of 90% or greater may not be needed (Ralston et al Pediatrics 2014)

* “Clinicians may choose not to administer supplemental oxygen if the oxyhemoglobin saturation exceeds 90% in infants and children with a diagnosis of bronchiolitis (Evidence Quality: D; Recommendation Strength: Weak Recommendation [based on low level evidence and reasoning from first principles]).”

Aktuelle FOAMed Infos rund um die klinische Notfallmedizin, Notfallmedizin und Intensivmedizin, auf den Spuren vom Skeptics Guide to emergency medicine

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Date: August 22nd, 2018

Reference: Riskin A, Erez A, Foulk TA, et al. Rudeness and Medical Team Performance. Pediatrics. February 2017

Guest Skeptic: Dr. Simon McCormick is an Emergency Medicine Consultant from Northern Ireland who works in Rotherham Hospital in Yorkshire, England. He is currently redeployed in Medical Education on “Burnout Sabbatical” but is hopeful of returning to the shop floor in the near future. He writes a blog called Broken Toy covering topics such as his experience with burnout, medical education and looking after each other. 

Case:  You are working in the emergency department (ED) and have just been involved in a difficult case in the resuscitation room. During the resuscitation, a relative of the patient you have been treating named Rudy makes a derogatory/rude comment about Emergency Medicine (EM) staff.

Background: Unfortunately, rudeness is a problem that is rife in medicine. It does not just come from patients and/or their relatives, as in this case, but can also come from the medical team. Specialties make fun of each other using unflattering stereotypes, seniors are unpleasant to juniors and physicians can say derogatory things to nurses.

This internal rudeness has traditionally been seen as just “part of medicine”, a way to “build a tribe” or just part of the black humour and banter needed to survive in a tough environment.

More recently, however, this has been questioned and people are now more inclined to think of the worst of this as a form of bullying and harassment and other, milder rudeness, as detrimental to the development of staff and harmful to a collaborative culture within medicine.

Perhaps even more worryingly, is the concern that rudeness has an impact on staff performance, actually putting patients at risk. That said, it is unlikely that we can eradicate rudeness completely from our working lives. However, is it perhaps possible to reduce the impact rudeness may haveon staff, either with some form of pre-emptive education or a post event debriefing whether the rudeness comes from the team or those patients and families we are trying to help.

Rudeness does not need to be part of medicine. A better option is to try kindness as outlined in the excellent book by Dr. Brian Goldman. We discussed Brian’s book on the SGEM Xtra called Don’t Give Up – The Power of Kindness.

Being rude might make us feel better sometimes but that is always at the expense of who we are being rude to. Whilst it might take a little effort, taking the time to try to understand why someone is behaving as they are, showing some empathy, can have real benefits. As we start to understand the issues behind their actions and reactions, we are given the opportunity to reach out and show some kindness which not only helps them, it also helps us by reconnecting with that basic human desire to be helpful. Instead of the win/lose of rudeness we get a win/win with kindness!

Clinical Questions:

1) Does rudeness affect the performance of a clinical team?

2) If it does, can we mitigate the effects of rudeness?

Reference: Riskin A, Erez A, Foulk TA, et al. Rudeness and Medical Team Performance. Pediatrics. February 2017

* Population: Neonatal Intensive Care Unit (NICU) staff, both physicians and nurses, working in a number of NICUs in Israel.

* Intervention: Staff were exposed to a controlled ...

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Date: August 25th, 2018

Guest Skeptic: Dr. Neil Parry is an Associate Professor of Surgery and Critical Care at Western University. He is the Medical Director of the Trauma Program for London Health Sciences Centre and the Site Chief of Surgery at Victoria Hospital. Dr. Parry is also a national member of the Committee on Trauma for the America College of Surgeons where he serves as a member of the ATLS Committee and as the Chair of the Surgical Skills Committee.

This is an SGEM Xtra episode and will be the last show before staring Season #7 on September 1st. It has been an incredible ride. There are almost 37,000 subscribers to the SGEM.

Our goal continues to be to cut the knowledge translation window down from over ten years to less than one year using the power of social media. Ultimately, we want patients to get the best care based on the best evidence. We also want to teach critical thinking skills and encourage skepticism.

 

DISCLAIMER:

These are Dr. Parry’s personal choices for the top 10 changes to ATLS and do not reflect the opinions of the ATLS committee, the Committee on Trauma of the American College of Surgeons, Western University or anyone else.

 

Dr. Parry briefly tells the story of Dr. James K. Styner plane crash in 1976 that inspired him to start what became the Advanced Trauma and Life Support (ATLS) program. The ALTS program has been taught in 86 countries around the world and under gone a number of updates over last four decades.

Here are the top 10 changes to ATLS 10th Edition according to Dr. Parry. You can listen to the SGEM podcast on iTunes to hear Neil expand on all the points listed below.

 

Top 10 Changes to ATLS 10th Edition

 

#1 – No More Lectures

All interactive case – based discussions

Students need to read manuals!

True adult education – no spoon feeding

 

 

#2 – New Skills Stations

Case-based unfolding scenarios for A,B,C,D,E’s

No longer anatomy based

More student interaction

 

 

#3 – “New/Honed” Skills for Instructors

Must engage students

Time management

Five step method for skills teaching

 

 

#4 – Shock

One litre crystalloid and early administration of balanced blood products for Class III-IV shock

Updated shock classification table to include blood products

Introduce concept of damage control resuscitation

 

#5 – Thoracic Trauma

Needle decompression 4-5th intercostal space, anterior axillary line for adults

Smaller chest tubes for hemothorax

Early management of blunt aortic injury

 

 

#6 – Head Trauma

Revised Glasgow Coma Scale

Introduce