25 50 mg PO once dally:maximum Severe psoriasis
Other disorders ol
hyperkeratinization (ichthyosis.
Datier's disease)
Monitoring
Cr at baseline:LFTs at baseline, then q1-2 wk until stable,then as clinically indicated:lasting lipid
panel atbaseline, then q1-2 wk until stable,then it long-term treatment or high-risk patient, continue
periodically:urine or serum pregnancy lest x 2 at baseline,qmo during trealmenl.then q3 mo for »3 yr
alter discontinuation:glucose ildiabeles:radiography periodically if long- term treatment
Contraindications
Women of childbearing potential unless strict contraceptive requirements are met
Drug interactions
Other systemic retinoids,methotrexate,tetracyclines,certain contraceptives
May be combined with PUVA phototherapy (known as re PUVA)
Side effects
Headache,nausea,diarrhea,abdominalpain
Reduce dose if impaired renal(unction
Plug Interactions
Cladribine. varicella vaccine,zoster vaccine
75 mg/d
Antivirals famciclovir (Famvir Chickenpox 1)
250 mg PO TIDx 7-10 d (for1st
episode of genital herpes)
125 mg P0 BID x 3 d (lor rccurrcnl
genital herpes)
H2V
Gcnilal herpes
Aculc and prophylactic lo reduce
transmission In infected patients
Herpes labialis
Side effects
Dimness,depression,abdominal pain
Reduce dose ilimpaired renal function
Drug interactions
cladribine.foscarnel, varicella vaccine,zostervaccine
Monitoring
BUIti'Cr x 2 at baseline, then q2 wk x 3mo.thenilstable,qmo: BP x 2.CBC.K \ Mg >•, lipid panel,uric acid al
baseline,then q2 wk x 3 mo.then qmo if stable, or more frequently if ad|ust dose;LFIs
Contraindications
Abnormal renal function,uncontrolled hypertension,maliqnancy (except NMSC).uncontrolled infection.
Immunodeficiency (excluding autoimmune disease),hypersensitivity to drug
Long- term effects preclude use of cyclosporine for »2 yr:discontinue earlier ilpossible
May consider rotating therapy with other drugs to minimize adverse effects of each drug
Monitoring
G6PD before treatment starts:CBC qwk x 4. gmo x 6.then gG mo thereafter:IFIs at baseline, then
periodically
Side effects
Neuropathy
Hemolysis (Vitamin C and (supplementation can help prevent this)
Ding interactions
Substrate of CYP2C8/9 (minor),2C19 (minor),2E1(minor).3A4 (major)
Often a dramatic response within hours
valacyclovir (Vallrex - )
1000 mg PO BID x 3 d
(for 1st episode ol genitalherpes)
500 mg PO BIDx 5 d
(for recurrentgenital herpes)
2.5-4 mg/kg/dP0 divided BID
Max 4 mg/kg/d
After 4 vrk may increase by 0.5
mg/kg/d q2 wk
Concomitant dose of magnesium
may protect the kidneys
Cyclosporine
(Ncoral
'
1
)
Psoriasis
May also be effective in:
Lichen planus
EM
Recalcitrant urticaria
Recalcitrant AD
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50 100 150 mg P0 once daily
tapering to 25 -50 mg P0 once
daily to as low as 50 mg 2x/wk
Dermatitis herpetiformis,
ncutiophilic dermatoses
Oapsonc
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D5IDermatology Toronto Notes 2023
Table 29. Common Oral Therapies
Drug Name Dosing Schedule Indications Comments
Doxycycline 100 mg PO BIO Contraindications
Pregnancy,hepatic impairment,drug hypersensitivity
Taking acitretin.isotretinoin,or penicillin antibiotic
Oral typhoid vaccine
Monitoring
Fasting lipid panel at baseline,then q1-2 wk until lipid response to isotretinoin is established or if risk
factors more frequently;IFTs at baseline,then ql 2 wk unlit stable; pregnancy test x 2 al baseline:glucose
frequently if risk factors
Contraindications
Teratogenic -in sexually active females.2 forms of reliable contraception necessary
Generally regarded as unsafe in lactation
Side effects
Decreased night vision,decreased tolerance to contact lenses,dry mucous membranes
May transiently exacerbate acne,dry skin
Depression,myalgia
Otuo interactions
Caution if used at the same time as tetracycline family antibiotics - both may cause pseudotumour cerebri
Discontinue vitamin A supplements
Orug may be discontinued at 16-20 wk when nodule count has dropped by >70%;a second course may be
initiated after 2 mo pro
Refractory cases may require >3 courses
Contraindications
Acne vulgaris
Rosacea
Bullous pemphigoid
Isotretinoin
(Accutane
Clarus
'
,
Epuris )
0.5-1mg/kg/d given once daily to Severe nodular and/or
achieve a total dose of 120 mg/kg inflammatory acne
Acneconglobala
Recalcitrant acne
Widespread comedonal acne
(20-24 wk)
100 400 mg P0 once daily,
depending on infection
Tinea corporis/cruris/versicolor:
200 mq P0 once daily x 7 d
Tinea pedis:200 mg P0 BID x 3 d
Toenails;200 mg PO BID x 3 d once
per mo.repeated 3x
Fingernail involvement only: 200
mg 8IDP0 x 3 doncepermo
Onychomycosis
Tinea corporis,cruris,pedis.
versicolor,capitis
Itraconaiole
(Sporanox ) CHF
Side effects
Seiious hepatotoxicity
Drug Interactions
Inhibits CVP3A4
Increases concentration of some drugs metabolized by thisenzyme (i.e.statins,diabetic drugs)
Give capsules with food,capsules must be swallowed whole
200-250 pgikgP0 weekly x 2 Onchocerciasis (USA only)
Take once as directed; repeat one Not licensed for use inCanada
Also effective for:scabies
Psoriasis
Ho significant serious side effects
Efficacious
Ivermectin
(Mcctizan ,
Stromectol )
Methotrexate
wk later
10 -25 mg qwk.PO.IM.or IV
Max:30 mgiwk
To minimize side effects,
administer with folic acid
supplementation:
1- 5 mg once daily
Monitoring
Pregnancy test at baseline:CBC albaseline,then q6 mo or more frequently if initial treatment, dose
change,elevated serum level risk,or chemotherapy use;BUNICr,IfIs at baseline,then q4- 8 wk or more
frequently if initial Tx. dose change,elevated serum levelrisk,or chemotherapy use:serum albumin at
baseline if psoriasis,then continue periodically:CXR at baseline;liver biopsy at baseline if psoriasis or if
RA with history of alcoholism,persistently abnormal baseline IfIs, or chronic HBV or HCV infection, then
if psoriasis repeat after total cumulative dose 1.5 g and each additional1-1.5 g; serum drug levels if renal
impairment,or high dose chemotherapy use
Contraindications
Pregnancy,lactation,alcohol abuse,liver dysfunction, immunodeficiency syndrome,blood dyscrasias,
hypersensitivity to drug
Restricted to severe,recalcitrant or disabling psoriasis not adequately responsive to other forms of
therapy
May be combined with cyclosporine to allow lower doses of both drugs
All combined OCPs arehelpful in acne but those listed on the left have undergone RCTs
Contraindications
Smoking,HIM.migraines with aura,pregnancy
Routine gynaecological health maintenance shoiid be up to date
A0
lymphomatoidpapulosis
May aIso be effective in:
cutaneous sarcoidosis
OCPs
(TriCydcn ,
Diane 35 ',
Alesse- )
1pill PO once daily Hormonal acne (chin,jawline)
Acne associated with polycystic
ovarian syndrome or other
endocrine abnormalities
Spironolactone 50 -100 mg P0 once daily alone or Hormonal acne (chin,jawline) Contraindications
with OCPs Acne with endocrine abnormality Pregnancy
Side effects
Menstrual irregularities at higher doses if not on OCPs
8reast tenderness,milddiuresis common
Risk of hyperkalemia - counsel patients to reduce intake of potassium rich foods such as bananas
Terbinafine
(lamisil )
250 mg P0 once daily x 2 wk
Fingernails xGwk
Toenails x 12 wk
Confirm diagnosis prior to
trealment
Onychomycosis
Tinea corporis,cruris,pedis.
capitis
Contraindications
Pregnancy,chronic or active liver disease
Drug interactions
Potent inhibitor of CYP2D6;use with caution when also taking p-btockers. certain anti-arrhythmic agents.
MA0Itype B,and/or anlipsychotics
Orug concentrates rapidly in skin,hair,and nailsal levels associated with fungicidal activity
Contraindications
Seveie renal or hepatic dysfunction
Tetracycline 250-500mg PO BID to TID Acne vulgaris
Taken1h before or 2 h after a meal Rosacea
Bullous pemphigoid
rt
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D55 Dermatology Toronto Notes 2023
Traumatic and Mechanical Disorders
PERNIOSIS
Definition
• abnormal inflammatory response to cold, damp, non-freezing conditions
Epidemiology
• common in the United Kingdom and northwestern Europe;common for those whose homeslack
central heating
• women, the elderly, and children arc most affected
Clinical Features
• single or multiple erythematous to blue-violet macules, nodules,or papules
• blistering or ulceration seen in severe cases
• lesions present on the distal toes and fingers, and less often on the heels, ears, and nose
• symptoms of burning, itching, or pain, lasting 1-3 wk
Pathophysiology
• unknown but may be associated with cryoglobulins or cold agglutinins
Differential Diagnosis
• chilblain lupus erythematosus, lupus pernio
Treatment
• warming clothing, avoidance of cold, damp conditions, keeping feet dry,smoking cessation
• nifedipine, nicotinamide, phenoxybenzamine,sympathectomy, and erythemogcnic UV B
phototherapy
TRAUMATIC AURICULAR HEMATOMA (CAULIFLOWER EAR)
. see Plastic Surgery, PL34
ANIMAL BITES
• see Cellulitis, D30
BITES
• see Plastic Surgery. PL11
BURN INJURIES
• see Plastic Surgery.PL18
FROSTBITE
• see Emergency Medicine. IR46
KELOIDS
• see Keloids,DIO
THERMAL INJURY
• see Plastic Surtterv. PLI8
UV LIGHT INJURIES
• see Sunscreens and Preventative therapy, D52
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Landmark Dermatology Trials
Trial Name Reference Clinical Trial Details
MELANOMA
Hodi el al. 2010 NEJM 2016; 376:311- Tillo:ImprovedSurvival with Ipilimumab inPatients with Metastatic Melanoma
Purpose:Tocompare ipilimumab administered with or without a glycoprotein 100|gp100) peplide vaccine to gp100 alone in patients with previously
treated metastaticmelanoma.
Methods:676 HLA-A*O201—positive patients with unresectable stage III or IV melanoma,were randomized in a 3:1:1ratio to receive ipilimumab-gp100
(n-403).ipilimumab alone (n-137),or gp100 alone (n
_136).
Results: Median survival was10mo among patients receiving ipilimumab plus gptOO.as compared with 6.4 mo among patients receiving gptOO alone and
10.1mo median survival with ipilimumab alone. No significant difference Insurvival between ipilimumab groups was noted.Grade 3 or 4 immune related
adverse events occurred in 10-16% ot patients treated withipilimumab and 3% treated with gplOO alone.
Conclusions:Ipilimumab.with or without a gp100 peptide vaccine,as compared with gp100 alone,improved overall survival in patients withpreviously
treated metastalicmelanoma.
NEJM 2011; 364:2607- Title:Improved Suivival with Vcmutalenib inMelanoma with BRAE V600E Mulation
Purpose:To compare the eflicacy of BRAE kinase inhibitor vemurafenib (PIX4032) vs. dacarbazine in patients with metastatic melanoma.
Methods:Phase 3 RCT comparing vemuralenib with dacarbazine in 676patients with untreated,metastatic melanoma with BRAE V600E mutation.Patients
were randomized to receive vemurafenib (960 mg orally twice daily) or dacarbazine (1000 mg/m'
of body-surface area intravenously every 3 vreeks).Coprimary endpoints:overall and progression-free survival.
Results: Al 6 mo.overall survival was 84% In the vemuralenib group and 64% in the dacarbazine group.Vemuralenib was associated witha relative
reduction of death risk by 63% and a reduction of 74% in the risk of either death or disease progression vs.dacarbazine. Response rates were reported
to be 48% for vemurafenib and 6% for dacarbazine.Common adverse events associated withvemurafenib:arthralgia,rash,fatigue,alopecia,
keratoacanthoma. photosensitivity,nausea,and diarrhea.
Conclusions:Vemurafenib improved rates of overall and progression-free survival in patients with previously untreated melanoma with the BRAE V600E
mutation.
I l l
BRIM - 3
2516
PSORIASIS
BE VIVID Lancet 2021.397:
475- 486
Title:Bimekizumab versus Ustekinumab for the Treatment of Moderate to Severe Plaque Psoriasis (BE VIVID):Efficacy and Safety from a 52 wk.Multicentre,
Double-blind.Active Comparator andPlacebo Controlled Phase 3 Trial
Purpose:To compare the elficacy and safety ol a 52 wk treatment withbimekizumab vs.placebo vs. ustekinumabIn patients withmoderate to severe
plaque psoriasis.
Methods:Multicentre RCT involving adults 18 yr of age or older with moderate to severe plaque psoriasis (Psoriasis Area and Severity Index [PASI] score
>12,>10% body surface area affected by psoriasis,and Investigator’s Global Assessment [IGA]score >3 on a five point scale).Patients were randomly
assigned (4:2:1) to bimekizumab 320 mg ever y 4 wk.ustekinumab 45 mg or 90 mg at wk 0and 4.then every12 wk,or placebo every 4 wk.At16 wk.
patients in the placebo group were switched to bimekizumab.
Results:The study enrolled 567 patients.At wk 16.85% of patients in bimekizumab group had PASI90 vs. 50% in ustekinumab group and 5% in placebo
group.Approximately84% patients in bimekizumab group had an IGA response vs.53% inustekinumab group and 5% inplacebo groups.Major cardiac
adverse events occurred in5 patients with pre-existing CV risk factors in the bimekizumab group whereas none occurred in the ustekinumab group.
Additionally,oral candidiasis rates were higher than placebo and ustekinumab. and one case of IB0 was recorded.
Conclusion:Bimekizumab was moie efficacious than ustekinumab and placebo in the treatment ol moderate to severe plaque psoriasis.Additional studies
may be needed to assess safety.
ADVANCE Title:Efficacy and Safety of Apremilast (Phosphodiesterase Inhibitor) in Patients with Mild-to-moderate Plaque Psoriasis
Purpose:Toevalualelhe effectiveness of apremilast in treating mild-to-moderate plaque psoriasis.
Methods: A phase 3. double-blind,placebo controlled study was conducted in 595 adults with mild-to-moderate psoriasis. Patients were randomized to
either 30mg twice daily oral apremilast or placebo (oral tablets olno pharmacological significance) for the first 16 wk. (he outcome of interest
was the achievement of a staticPhysician Global Assessment score of 0 (clear) or1(almost clear).
Results:Asignificantly larger proportion of the apremilast group met the desired static Physician Global Assessment response rate when compared with
the placebo group (21.6% vs.4.1%).
Conclusions:Apremilast proved effective as a treatment for mild-to moderate plaque psoriasis.
J Am Acad Dermatol
2022;86|1):77
ATOPIC DERMATITIS
Title:Tralokinumab (Monoclonal Antibody) Plus TopicalCorticosteroids (TCS) for theTreatmentofModerale-lo-severe Atopic Dermatitis
Purpose: to evaluate the safety and effectiveness of tralokinumab in treating moderate to severe atopic dermatitis
Methods: A double-blind placebo study was conducted using 380patients. 253 ol which were landomized to the treatment group (subcutaneous
tralokinumab 300 mg every 2 wk with TCS as needed over 16 wk) and the remainder to the placebo group (placebo every 2 wk with TCS as needed over 16
wk).The outcome of interest was a 75% improvement in the Eczema Area andSeverity Index (EASI).
Results:After 16 wk of treatment there was a significantly larger proportion of patients treated with tralokinumab (56%) that achieved the EASI benchmark
when compared to the placebo group (35.7%).
Conclusions:Iralokinumab in combination with the current standard olcare was proven to be effective and well tolerated in treatment for atopic
dermatitis.
EC21RA BrJ Dermatol
2021:184(31:450
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D57 Dermatology Toronto Notes 2023
References
Abbvie.Product monograph including patient medication information Skyrizi.Abbvie:2019 Apr 17:[updated 2020 Mar 11:cited 2020 Apr 28],Available from:https://www.abbvie.ca/content/dam/abbvie-dotcom/
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6th ed and 7th ed.New York:McGraw Hill.2009.
392 25432.
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Emergency Medicine
Vinyas Harish, Danny Ma, Kwasi Nkansah, and Tsz Ying So, chapter editors
Ming Li and Dorrin Zarrin Khat, associate editors
Vijithan Sugumar, HBM editor
Dr. Mark Freedman, Dr. Laura Hans, Dr. Adam Kaufman, Dr. Jo Jo Leung, and Dr. Kaif Pardhan,stafi
editors
Toxicology
Approach to the Overdose Patient
“ABCD3EFG" ot Toxicology
D1- Universal Antidotes
D2-Draw Bloods
D3 -Decontamination and Enhanced Elimination
E -Expose and Examine the Patient
F - Full Vitals,ECG Monitor, Foley,X-Rays
G -Give Specific Antidotes and Treatments
Alcohol Related Emergencies
Disposition from the Emergency Department
Psychiatric Emergencies.
Approach to Common Psychiatric Presentations
Acute Psychosis
Suicidal Patient
Common Paediatric ED Presentations
Modified Glasgow Coma Score
Respiratory Distress
Febrile Infant and Febrile Seizures
Abdominal Pain
Common Infections
Child Abuse and Neglect
Common Medications
Landmark Emergency Medicine Trials
References
Acronyms
Patient Assessment/Management
1. Rapid Primary Survey
2. Resuscitation
3.Secondary Survey
Ethical Considerations
Traumatology.
Considerations for Traumatic Injury
Head Trauma
Mild Traumatic Brain Injury
Spine and Spinal Cord Trauma
Chest Trauma
Abdominal Trauma
Genitourinary Tract Injuries
Orthopaedic Injuries
Wound Management
Approach to CommonED Presentations.
Abdominal Pain
Acute Pelvic Pain
Altered Level of Consciousness
Chest Pain
Headache
Joint and Back Pain
Seizures
Shortness of Breath
Syncope
Sexual Assault
Medical Emergencies.
Anaphylaxis and Allergic Reactions
Asthma
Cardiac Dysrhythmias
Acute Exacerbation of COPD
Heart Failure
Venous Thromboembolism
Diabetic Emergencies
Electrolyte Disturbances
Hypertensive Emergencies
Acute Coronary Syndrome
Sepsis
Stroke and Transient Ischaemic Attack
Otolaryngological Presentations and Emergencies
Epistaxis
Gynaecologic/Urologic Emergencies
Vaginal Bleeding
Pregnant Patient in the ED
Nephrolithiasis (Renal Colic)
Ophthalmologic Emergencies
DermatologicEmergencies
Environmental Injuries
Heat Exhaustion and Heat Stroke
Hypothermia and Cold Injuries
Inhalation Injury
Bites
Near Drowning
ER2 ER49
ER2
ER7
ER56
ER57
ER18
ER60
ER61
ER62
ER29
ER39
ER40
ER42
ER43
ER45
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Toronto Notes 2023
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F.Rl Emergency Medicine
ER2 Emergency Medicine Toronto Notes 2023
Acronyms
AAA abdominal aortic aneurysm D10W
AUG arterial blood gas
ACEI angiotensin-converting enzyme D25W
inhibitor
ACLS Advanced Cardiac Life Support
ACS acute coronary syndrome
AED automatic external defibrillator
AEib atrial fibrillation
anion gap
ARDS acute respiratory distress
syndrome
AVN avascular necrosis
AVPU alert,voice,pain,unresponsive EM
AXR abdominal x-ray
Bi-PAP bilevel positive airway pressure ETT
BSA body surface area
BUN blood urea nitrogen
CAS Children's Aid Society
CIWA Clinical Institute Withdrawal
Assessment for Alcohol
CNS central nervous system
CPAP continuous positive airway
pressure
cerebral perfusion pressure HI
CRP c-reactive protein
CVA costovertebral angle
CVS cardiovascular system
DSW dextrose 5% in water
dextrose 10%in water
dextrose S0%in water
dextrose 25%in water
disseminated gonococcal
infection
disseminated intravascular
coagulation
diabetic ketoacidosis
digital rectal exam
delirium tremens
deep vein thrombosis
emergency department
erythema multiforme
erythrocyte sedimentation rate
endotracheal tube
focused assessment with
sonography for trauma
forced expiratory volume in 1
second
fresh frozen plasma
gastroesophageal reflux disease pRBC
glasgow coma scale
head eyes ears nose throat PTT
head injury
head and neck
inflammatory bowel disease ROM
irritable bowel syndrome
intercostal space
INR International normalized ratio ft-PA
IVC inferior vena cava
LBBB left bundle branch block
IOC level of consciousness
IP lumbar puncture
LSD lysergic acid diethylamide
LVH left ventricular hypertrophy SJS
MAP mean arterial pressure
MDI metered dose inhaler
recombinant tissue plasminogen
activator
subarachnoid hemorrhage
spontaneous bacterial
peritonitis
spinal cord injury
Stevens-Johnson syndrome
sympathetic nervous system
shortness of breath
selective serotonin reuptake
inhibitor
staphylococcal scalded skin
syndrome
ST elevation myocardial
infarction
traumatic brain injury
tricyclic antidepressant
tetanus,diphtheria,acellular
pertussis
toxic epidermal necrolysis
transient ischaemic attack
toxic shock syndrome
venous blood gas
ventricular fibrillation
ventricular tachycardia
venous thromboembolism
D50W
SAH
DGI SBP
DIC SCI
DKA SNS
AG DRE SOB
DT MDMA methylenedioxymethamphetamine
MMSE mini-mental state examination
MVC motor vehicle collision
NS normal saline
NSTEMI non-ST elevation myocardial
infarction
pelvic inflammatory disease
PNS parasympathetic nervous
system
POG plasma osmolar gap
packed red blood cells
SSRI
DVT
ED SSSS
=5F STEMI
FAST TBI
PID TCA
FEV1 Tdap
FFP TEN
GERD TIA
GCS PT prothrombin time TSS
partial thromboplastin time VBG
relative afferent pupillary defect VFib
VTach
HEENT
CPI> RAPD
H&N RBBB right bundle branch block
range of motion
rapid primary survey
rapid scgucncc induction
IBD VIE
IBS RPS
ICS RSI
Patient Assessment/Management
1. Rapid Primary Survey
• Airway maintenance with (.
'
-spine control
• Breathing and ventilation
• Circulation (pulses, hemorrhage control)
• Disability (neurological status)
• Exposure (complete) and Environment (temperature control)
continually reassessed during secondary survey
changes in hemodynamic and/or neurological status necessitates a return to the primary survey
beginning with airway assessment
• IMPORTANT: always watch forsigns ofshock while doing primary survey
• addressing the “ABCs" is the hallmark of the emergency department
• in the setting of cardiac arrest, the approach changes to the “CABs":chest compressions, airway,
and breathing
• CAB can also be applied in massive trauma situations in the setting of massive blood loss to treat
hypovolemic shock
Approach to the Critically III Patient
1Rapid Primary Survey (RPS)
2.Resuscitation (often concurrent with
RPS)
3.Detailed Secondary Survey
4. Definitive Care
Signs of Airway Obstruction
• Agitation,confusion,“universal
choking sign"
• Respiratory distress
• Failure to speak,dysphonia,stridor
• Cyanosis
A. AIRWAY
• first priority is to secure airway
• assume a cervical injury in every trauma patient and immobilize with collar
• assess ability to breathe and speak
• listen for evidence of airway obstruction (e.g. stridor)
• can change rapidly, therefore reassess frequently
• assess for facial fractures/edema/burns(impending airway collapse)
Airway Management
• anatomic optimization to allow for oxygenation and ventilation
1. Basic Airway Management
• protect the C-spine
• chin lift (if C-spine injury not suspected) or jaw thrust to open the airway
• sweep and suction to clear mouth of foreign material r
2. Temporizing Measures
• nasopharyngeal airway (if gag reflex present, i.e. conscious)
• oropharyngeal airway ( if gag reflex absent, i.e. unconscious)
• “rescue” airway devices (e.g. laryngeal mask airway,Combitube*)
• especially for children <8 yo, transtracheal jet ventilation through cricothyroid membrane ( rarely
used and best to consider opting for a definitive airway)
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ER3 Emergency Medicine Toronto Notes 2023
3. Definitive Airway Management
• t i l l intubation (with in-line stabilization of (.
'
-spine if applicable)
orotracheal ± KM preferred
• nasotracheal may be better tolerated in conscious patient
•surgical airway (if unable to intubate using oral/nasal route and unable to ventilate)
•cricothyroidotomy
Medications that can be Delivered
via ETT
NAVEL
Naloxone (Narcan*
)
Atropine
Ventolin- (salbutamol)
Epinephrine
Lidocaine
Contraindications to Intubation
•see fable 2, Anesthesia.A8
upraglottic/glottic pathology that would preclude successful intubation
•provider safety: e.g. SARS-CoV-2 (COVTD-I9) precludes intubation, CPR, and other aerosol generating
procedures in the absence of full PPE
•s
Trauma requiring intubation
Indications for Intubation (4 P's)
• Patent airway
• Protects against aspiration (e g.
decreasing GCS <8)
• Positive pressure ventilation
• Pulmonary toilet (suction)
I
1
No immediate need Immediate need
l
i * *
C Apneic Breathing -
spme x-ray
1
I YES 1
NO
^
negative"
Oral ETT
URSI)
positive
Fiberoptic
^
ETT or
nasal ETT or RSI
1 1
Oral ETT Oral ETT
(no RSI)
Nasal ETT or oral ETT
URSI) Rescue Techniques in Intubation
• Bougie (used like a guidewire)
• Glidescope-
• Lighted stylet (uses light through skin
to determine if ETT in correct place)
• Fiberoptic intubation (uses fiberoptic
cable for indirect visualization)
J L J
Unable Unable Unable
I I i
Rescue devices or
cricothyroidotomy
Rescue devices or
cricothyroidotomy
Rescue devices or
cricothyroidotomy
‘
Note:clearing the C spine requires radiologic and clinical assessment
Video Laryngoscopes Figure1. Approach to endotracheal intubation in an injured patient
Stylets
Bonfil
Rigid and flexible laryngoscope (RIFL)
SenseScope
B. BREATHING
Breathing Assessment
• quantitative measures of respiratory function:rate, oximetry, ABG, A-a gradient
• Look Guide Channels
AlrTraq
Pentax AWS
Res-Q-Scope II
Traditional (non-guided)
Glidescope
• mental status(anxiety, agitation, decreased LOC), chest movement (bilateral vs. asymmetrical),
respiratory rate/effort, nasal flaring, increased work of breathing
• Listen
auscultate for signs of obstruction (e.g.stridor), breath sounds,symmetry of air entry, air
escaping, adventitioussounds (e.g. wheezes,crackles)
• Feel
tracheal shift, chest wall for crepitus(e.g.subcutaneous emphysema, rib fracture), flail segments,
sucking chest wounds Noisy breathing is obstructed breathing
until proven otherwise
Management of Breathing
• treat likely underlying cause (e.g. bronchodilalors, epinephrine, diuresis)
• optimize oxygenation: nasal prongs > simple face mask > venturi mask > non-rebreather mask >
high-flow nasal cannula > CPAP/BiPAF (in order of increasing l it)
’
)
• bag-valve mask and CRAP to supplement inadequate ventilation
OJ Delivery Methods
FIO. Amount
C. CIRCULATION Given
Nasal Prongs 25 40%
Face Mask 40 60%
80-90%
161/nwi
5 10 L/min
ISUmin
Definition of Shock
• inadequate organ and tissue perfusion with oxygenated blood (brain, kidney, extremities)
Honrebreather
Table1. Major Types of Shock
High-flow up ID 100% 15 GOUmin
Nasal
Cannula
CPAP/BiPAP up to100%
Hypovolemic Cardiogenic Distributive Obstructive
Hemorrhage (external and Myocardial ischaemia
internal)
Severe burns
High output fistulas Cardiomyopathies
Dehydration (diarrhea.DKA) Cardiac valve problems
Septic (seeSepsis.CR3S) Cardiac tamponade (see Chest trauma.CR11)
Anaphylactic (see Anophflaxis Tension pneumothorax { seeChest haumo.IRtt)
and AllergicReactions, fR29) PE (see Venous thromboembolism, CR33)
Neurogenic (spinal cord injury) Aortic stenosis
Constrictive pericarditis
Dysrhythmias r“i
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CHF
Clinical Evaluation
• early:tachypnea, tachycardia, narrow pulse pressure, reduced capillary refill, cool extremities (except
neurogenic and septic shock), and reduced central venous pressure
• late: hypotension, altered mental status, reduced urine output
m +
Shock in a trauma patient is hemorrhagic
until proven otherwise
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ER1Emergency Medicine Toronto Notes 2023
Table 2. Estimation of Degree of Hemorrhagic Shock
Class II III IV
Causes cf Shock
<750 cc 750-1500 cc
15-30%
1500-2000cc
30 40%
Blood Loss >2000 cc
% of Blood Volume
Pulse
Blood Pressure
Respiratory Rale
Capillary Refill
Urinary Output
Fluid Replacement
SHOCKED
Se ptic.spinal/neurogenic
Hemorrhagic
Obstructive (e.g.tension
pneumothorax, cardiac tamponade. PE)
Cardiogenic (e.g. blunt myocardial
injury, dysrhythmia. Ml)
anaphylactiK
Endocrine (e.g.Addison'
s, myxedema,
coma)
Drugs
<15% >40%
<100 >100
Normal
>120 >H0
Normal Decreased Decreased
20 30 35 >45
Decreased
20cc/h
Crystalloid
Oecreased
lOcc/h
Crystalloid * blood
Oecreased
None
Crystalloid *blood
Normal
30 cc/lt
Crystalloid
Management of Hemorrhagic Shock
• clear airway and assess breathing either first orsimultaneously
• apply direct pressure on external wounds while elevating extremities. Do not remove impaled objects
in the emergency room setting as they may tamponade bleeds
• start two large bore (14-16 G) IVs in the brachial/cephalic vein of each arm
• permissive hypotension with pRBC transfusion,ideally crossmatched. If crossmatched blood is
unavailable in a timely manner, consider O- for women of childbearing age and 0+ for men. Use ETP,
platelets or tranexamic acid in early bleeding. If available, activate '
massive transfusion protocol’
• consider common sites of internal bleeding (abdomen, chest, pelvis,
long bones, G1 tract) where
surgical intervention may be necessary
Common Sites of Bleeding
• External (e.g.scalp)
• Chest
• Abdomen (peritoneum,
retroperitoneum)
. Pelvis
• Long bones
• Gl
D. DISABILITY
• assess LOG using GCS
• pupils
• assess equality,size,symmetry,reactivity to light
• unequal or sluggish suggests local eye problem or lateralizing CNS lesion
• non-reactive pupils + decreased LOG:structural cause (especially if asymmetric)
• lateralizing motor deficits
Fluid Resuscitation
Give bolus until HR decreases, urine
output increases,and patient stabilizes
• Maintenance:4:2:1 rule
• 0-10 kg:4 cc/kg/h
• 10-20 kg:2 cc/kg/h
• Remaining weight1cc/kg/h
• Replace ongoing losses and deficits
(assume10% of body weight)
Shortcut for calculating maintenance
fluidsfor any patient >20kg: Fluid rate
fin cc/hr) - 40 + patient'
s weight in kg
Glasgow Coma Scale
• GGS is for use in trauma patients with decreased LOG;good indicator ofseverity of injury and
neurosurgical prognosis
• most useful if repeated; change in GGS with time is more relevant than the absolute number
• less meaningful for metabolic coma
• patient with deteriorating GCS needs immediate attention
• prognosis based on best post-resuscitation GCS
• reported as a 3-partscore: Eyes + V erbal + Motor = Total
• if patient intubated, GCS score reported out of 10 + T(T = tubed, i.e. no verbal component)
Table 3. Glasgow Coma Scale Unilateral. Dilated. Non-Reactive Pupil
• Focal mass lesion
• Epidural hematoma
• Subdural hematoma
Eyes Open Best Verbal Response Best Motor Response
Spontaneously
To voice
To pain
No response
Obeys commands
Local:res to pain
Withdraws from pain
Decorticate (flexion)
Decerebrate(extension)
Answers questions appropriately 5 6
Confused,disoriented
Inappropriate words
Incomprehensible sounds
No verbalresponse
4
3 4 5
2 3 4
1 2 3
1 2
No response 1
13-15 = mild injury. 9-12 - moderate injury. <8-severe injury See Table 36.fPS/tor UoaTedC-CS tor tfonts c.rdcb.
-i&eo
E. EXPOSURE/ENVIRONMENT
• expose patient completely and assess entire body for injury; log roll to examine back
• DRE for trauma patients
• keep patient warm with a blanket ± radiant heaters; avoid hypothermia
• warm IV tluids/blood
• keep providerssafe (contamination, combative patient)
2. Resuscitation Contraindicationsto Foley Insertion
• Blood at urethral meatus
• Scrotal hematoma
• High-ridmg prostate on DRE
ri
• done concurrently with primary survey
• attend to ABCs
• manage life-threatening problems as they are identified
• vital signs q5-15 min
• EGG, BP, and O’
monitors
• Eoley catheter and NG tube if indicated
• tests and investigations:CBC, electrolytes, BUN,Cr, glucose, amylase,1NR/PIT,
P-hCG, toxicology
screen, cross and type
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NG Tube Contraindications
• Significant mid-face trauma
• Basal skull fracture
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ER5Emergency Medicine Toronto Notes 2023
Table 4. 2010 AHA CPR Guidelines with 2020 Updates
Step/Action Adult:>8 yr Child:1-8 yr Infant:
‘
1yr
Airway Head till-chin lilt;jaw thrust without head or tension ilconcern lor spinal injury
Breaths 2 breaths at1stbrealh - slop once see chest rise
Severe Foreign-Body Airway
Obstruction
Abdominal thrust (if conscious) Back blows and chest
compressions
Compressions
Compression landmarks In the centre of the chest,lower hallof the sternum Just below nipple line
Compression method:push
hard and fast,and allow for
complete recoil
2 hands:heel of1hand with heel
of second hand on top
2hands:heel of1hand with
second on top,or
1hand:heel of1hand only
2 fingers,or thumbs
About
'
h to'
Compression depth 2-2.4inches h the depth of the chest
See Anesthesia,A32 forACLS Guidelines Compression rate 100-120/min with complete chest wall recoil between compressions
Compression-ventilation ratio 30 compressions to 2 ventilations
Compression-only CPU Hands- only CPR is preferred if the bystander is not trained or does not feel confident in their ability to provide
conventional CPR or if the bystander is trained but chooses to use compressions only
Defibrination Immediate defibrillationif a shockable rhythm (ventricular fibrillation or ventricular tachycardia)is identified
Compressions|5 cycles/2 min) and use A CO if unwitnessed arrest
Manual defibrillators are preferred for children and infants but can use adult dose AEO ila manual
defibrillator is notavailable
3. Secondary Survey
•done after primary survey once patient is hemodynamically and neurologicallv stabilized
•identifies major injuries or areas of concern
•full physical exam and Cl (C-spine, chest, abdomen, and pelvis-required in blunt trauma, consider
T-spine and L-spine if indicated)
HISTORY
•
“SAMPLE”:Signs and symptoms, Allergies, Medications, Past medical history, Last meal, Events
related to injury
FAST viow: Normal FAST view: Free Fluid
1. Subxiphoitl Poricarclial Window
heart chambers pericardial elfusion (t) o
2. Perisplenic
spleen (S), L kidney (K) free fluid (F)
3. Hepatorenal (Morrison s Pouch)
liver (L),kidney (K) blood IBL)
<
^
>
4. Polvic/Rotrovosical (Pouch of Douglas)
bladder (Bl free fluid (F) r-i
L J
+
Figure 2.Four areas of a FAST
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ER6 Emergency Medicine Toronto Notes 2023
PHYSICAL EXAM (see Traumatology, ER7)
Head and Neck
• palpation of facial bones,scalp
Chest
• inspect for midline trachea and flail chest
• auscultate lung fields
• palpate for subcutaneous emphysema
Abdomen
• assess for peritonitis, abdominal distention, and evidence of intra-abdominal bleeding
• DRE for Cil bleed, high-riding prostate, and anal tone
Musculoskeletal
• examine all extremitiesfor swclling, deformity, contusions, tenderness, ROM
• check for pulses (using Doppler probe) and sensation in all injured limbs
• log roll and palpate thoracic and lumbar spines
• palpate iliac crests and pubic symphysis and assess pelvic stability (lateral, AP, vertical)
Signs of Increased ICP
• Deteriorating IOC (hallmark)
• Deteriorating respiratory pattern
• Cushing reflex (high BP. low HR.
irregular respirations)
• lateralizing CNS signs(e.g. cranial
nerve palsies, homiparcsis)
• Seizures
• Papilledema (occurs late)
• N/V and headache
Neurological
• tiCS
• full cranial nerve exam
• alterations of rate and rhythm of breathing are signs of structural or metabolic abnormalities with
progressive deterioration in breathing indicating a failing CNS
• assessspinal cord integrity
• conscious patient: assess di
• unconscious patient:response to painful or noxiousstimulus applied to extremities
istal sensation and motor function
INITIAL IMAGING
• non-contrast CT head/face/C-spine (rule out fractures and bleeds)
• CXR
• FAST'
(see Figure 2, ER5 ) or CT abdomen/pelvis (if stable)
• pelvis x-ray
Non-contrast head CT is the best
imaging modality for intracranial injury
Ethical Considerations
Consent to Treatment:Adults
• see Ethical. Legal, and Organizational Medicine.ELOM11
• Emergency Rule: consent is not needed when a patient is at imminent risk from a serious injury AND
obtaining consent is either:a) not possible, OR b) would increase risk to the patient
assumes that most people would want to be saved in an emergency
• any capable and informed patient can refuse treatment or part of treatment, even if it islife-saving
• be aware of who the legalsubstitute decision maker (SDM) is and contact them early
• exceptions to the Emergency Rule -treatment cannot be initiated if:
a competent patient has previously refused the same orsimilar treatment and there is no evidence
to suggest the patient’
s wishes have changed (e.g. after an SDM has been contacted to clarify
patient’s wishes)
an advanced directive is available (e.g.do not resuscitate order)
NOTE: refusal of help in a suicide situation is NOT an exception; care must be given
• if in doubt,initiate treatment
• care can be withdrawn if necessary at a later time or if wishes are clarified by family
Consent to Treatment:Children
• treat immediately if patient is at imminent risk
• parents/guardians have the right to make treatment decisions, up to the age of 16 (beyond age 16, the
patient can be considered an emancipated minor)
• if parents refuse treatment that is considered life-saving or will potentially alter the child’
s quality of
life,CAS must be contacted - consent of CAS is needed to treat
Jehovah'sWitnesses
. Capable adults have the right to
refuse medical treatment
• May refuse whole blood. pRBCs.
platelets,and plasma even if
considered life-saving
• Should be questioned directly about
the use of albumin, immunoglobulins,
hemophilic preparations
• Do not allow autologoustransfusion
unlessthere is uninterrupted extra
corporeal circulation
• Usually ask for the highest possible
quality of carewithout the use of the
above interventions(e.g.crystalloids
for volume expansion, attempts at
bloodlesssurgery)
• Patient will generally sign hospital
forms releasing medical staff from
liability
• Most legal casesinvolve children of
Jehovah'
s Witnesses; if life-saving
treatment is refused, contact CAS
Other Issues of Consent
• consent is required for HIV testing and/or administration of blood products
• however, if delay in substitute consent for blood transfusions puts patient at risk, transfusions can be
given
Duty to Report
• law may vary depending on province and/or state
• e.g. gunshot wounds,suspected child abuse, various communicable diseases, medical unsuitability to
drive, risk of substantial harm to others
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