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Please note that clinical judgement
supersedes all guidelines
Consent forms
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Go into the patient's room & log into the computer.
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Open the Consents tab in Epic.
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Search "blood" or "procedure" and complete the form.
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Set "Relationship to "Self" if you are consenting the patient and not a proxy.
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Discuss the procedure/blood consent with the patient as you normally would.
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Since you are the one at the computer (not the patient), ask the patient for consent to sign the form on their behalf. Then, click the button in front of them to sign on their behalf.
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If you are using a proxy (eg. patient's spouse), ask them to come to the computer to sign with the mouse.
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Sign for yourself and click done.
Chest Tubes
BEFORE PLACEMENT
TRAUMA PATIENTS
1. Stable trauma – consult before
2. Unstable trauma – trauma activation
MEDICAL PATIENTS
1. Primary PTX (ex: young, tall person) – no consult
2. Secondary PTX (ex: COPD) – no consult
3. Recurrent primary PTX – consult
4. Recurrent secondary PTX – no consult
In addition to the EPIC consult the involved ED attending should call the trauma attending about the case.
DURING PLACEMENT
TRAUMA PATIENTS
1. EM will place the tube on odd days and Surgery will place the tube on even days. Odd/even switch at 0700.
2. When EM is on to place the chest tube surgery needs to be present during placement as they will be the ones managing the tube in-house. This should be a Surgery Chief Resident, Trauma Fellow, or Surgery Attending in the room at the time.
3. The EM attending should be sterile and “at the elbow” of the resident placing the tube to ensure proper procedure is followed and the placement is good.
MEDICAL PATIENTS
1. For medical chest tubes that will be admitted to surgery points 1-3 above still apply.
2. For medical chest tubes that will be admitted to a non-surgical service EM will place the tube and the EM attending should still be sterile and “at the elbow” of the resident placing the tube.
Dual sequential defibrillation
Intubation
RSI Trial
Exclusion Criteria
- Pregnant (Do not need pregnancy test prior to inclusion. Exclude patients who are known to be pregnant or are obviously gravid.)
- Prisoner
- Pediatric (patients 18/19 yo in DECC are not eligible)
- Major trauma (all alerts/activations)
- Red "RSI opt out" bracelet present
If patient is eligible, senior resident will assign someone to complete data collection sheet during intubation
Do not throw away or reuse open envelopes (once opened, the form must go into the RSI lockbox)
Procedural sedation
- Complete pre-procedure form prior to all sedations
- MD/DO must push medications (residents may push meds under direct supervision of attending)
US-guided nerve blocks
​Do NOT block:
- Deep Plexus (ESP, PENG, supraclavicular) in anticoagulated patient (definition here)
- Pelvic or thorax in pregnancy (see link above)
- Any neurovascular deficit
- Combo ulnar and radial shaft fracture
- Humeral shaft or supracondylar fracture
- Pilon ankle fracture
- >2 foot fractures
- Tibial plateau/shaft fracture
- Crush injuries
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Consult before block:
For any injury requiring a consult during the ED visit, discuss with consultant prior to performing block
- Distal femur or shaft fracture
- Ankle fracture or dislocation
- Shoulder dislocation WITH fracture
Chloroprocaine ONLY (w/ consult)
- Elbow dislocation
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Distal radius fracture
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