Trauma -> will need a man scan, intoxicated and difficult exam, open fractures
Stroke -> 10-minute goal door to CT time
Medical – > hypotension, hypoxia, AMS, seizure, shock
Sedations, procedures, cardioversion, etc.
PGY-1 roles
Help transfer from EMS stretcher to bed
ABCs, Exposure, Blankets
FAST exam -> use the barcode scanner, save clips, END EXAM, clean probe with grey wipe, interpret and sign in Qpath, /bedsideultrasound pulls interpretation into note
If penetrating, then start with cardiac view
If blunt, then start with RUQ view
PGY-2 and PGY-3 roles
Consider am I comfortable waiting several hours for their workup to start resulting?
Who to keep (trauma) -> man scan?, trustable exam?, vital sign derangements?, fracture/dislocation needing intervention?, elderly fall on thinner and isolated GSW to the extremities are common rollouts but do a thorough exam first
Who to keep (medical) -> hypotension, hypoxia, most respiratory intervention, intubated transfer patients are common rollouts
Who to keep (stroke) -> mostly keep all of these unless outside of window (>24 hours)
Get their last known normal, SBP, glucose, neuro exam, then call stroke attending
Level 1 criteria: confirmed SBP <90, respiratory compromise, blood products in route, GSW to the “box”, GCS <9 due to trauma, Emergency Physician discretion
Know the gender! Women receive O- blood. Men receive O+ blood
Room 9 Bay 1 -> has the most space, rigid stylet for VL intubations
Room 9 Bay 3 -> has chest tube and difficult airway cart
Buprenorphine in the ED
Removal of X-waiver this past year via the MATE Act 2023
Opioids -> synthetic in nature like fentanyl
Opiates -> derived from poppy so opium, morphine, and codeine
Heroin synthesized in 1874 and thought to be safe and less addictive than morphine
Methadone
Invented in the 1940s and was created to help with opium and morphine shortage
Full opioid agonist. Started being used as maintenance therapy. Dispensed as a daily medication because it is a schedule two drug not covered under original DATA legislation, unlike suboxone which is a schedule three drug and is covered
Causes prolonged QT. End of T wave finishes greater than ½ the RR interval
Opiate Use Disorder (OUD)
Specific criteria from DSM-5
Withdrawal timeline: symptom peak at 72 hours (nausea/vomiting/diarrhea, etc.)
Start suboxone while they are already in withdrawal
Use the COWS score to grade withdrawal symptoms
Less than 13 is mild, 13-24 is moderate, 25-36 moderately severe, more than 36 is severe withdrawal
Buprenorphine
Partial agonist for the mu receptor
Ceiling effect for pain control, respiratory depression with minimal euphoria
Cannot be injected IV (due to naloxone)
Minimal side effects and contraindications (acute liver failure)
2% bioavailability of naloxone when taken sublingually, so does not affect buprenorphine absorption
Trying to use opioids after taking suboxone is not particularly effective because buprenorphine is saturating receptors
Comes in 8mg (buprenorphine)/2mg (naloxone) and 2mg (buprenorphine)/0.5mg (naloxone)
Try to start with 8mg on day one, 16mg (8mg BID) day two, etc.
Can start at COWS of 8 (with objective signs) or 12 without
Can always start with test dose of 2mg. If they get worse, then likely used opioids more recently than they say or withdrawal is not severe enough. If they get better, then safe for higher dose
Precipitated withdrawal -> can either do supportive care or give higher doses of suboxone
Air Methods
Benefits of an air ambulance -> saves time (most benefit when ground time is >1 hr), ability to give blood products, preserves “golden hour” of resuscitation
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