Front Room Rules

Front Room Rules 150 150 Richie Cunningham

Here at ‘Copa, our ED is divided into the “Front” and the “Back.” The stable(ish) patients will go to the back of the ED, since they (relatively) have time to wait for their evaluation, workup, treatment, etc. Any patient who is or may be critically ill (dysrhythmias, hypotension, hypoxia, cardiac arrest, etc) goes to the “Front Room” which is our resuscitation bay. Starting in our second year, we have dedicated “Front Room Shifts” where we get any and all critically ill patients that walk (or are rolled) through the door. This is a document I started at the beginning of second year that covers my “Front Room Rules” or basic guidelines, tips, and tricks for approaching the critically ill. This is a living document and as such has been edited mercilessly since its inception. I fully recognize that I am just a second year emergency medicine resident (a lot of this is my opinion, gained from my personal experience and reading) so I welcome any feedback, criticism, thoughts, additions, or subtractions in the comments section below. That being said, let’s begin with an important disclaimer:

The first “rule” of mine is that we should avoid absolutes at all costs in medicine. All absolute statements here (those including the words every, always, all, never, etc) are used for rhetorical purposes and should not be taken to imply universality or infallibility. None of these rules are set in stone, and flexibility and adaptability are essential to what we do. Follow them according to your own discretion and gestalt.

Moving along to rule number…

  1. Every front room patient gets two PIVs (at least 20 gauge, larger bore if possible; see table) or one central line (IO’s if necessary) upon initial evaluation. Don’t leave the room until you have access!
    • Includes patients moved from the back to the front for procedural sedation (or for any other reason, for that matter)
    • Place one yourself along with nursing (landmark-based PIV placement is an underrated and essential skill for emergency physicians, IMO)
    • Try an EJ before jumping to US-guided IVs
      • Very useful for CHF patients with JVD
    • Don’t hesitate to place an IO. Barring a central line this may be your best point of access
    • If patient requires a contrast-enhanced CT, they need at least a 20 gauge proximal (AC or above) point of access in the upper extremity (EJs typically not sufficient, CVCs are)
    • If large bore PIVs are unobtainable and the patient requires rapid fluid or blood administration (think GI bleed) place a sheath introducer/Cordis
    • Use pressure bagging for hemodynamically unstable patients (applies to Cordis/RIC too)
    • PIV > triple-lumen CVC:

  2. When establishing access, consider obtaining blood in a heparinized syringe and run a point-of-care venous blood gas+electrolytes
    • Check pH for quick DKA dx and eval for acidosis if RSI necessary
    • Eval for hyperkalemia as contraindication for succ (also quick dx of hyperkalemia)
    • Eval for hyponatremia in status epilepticus
    • If in cardiac arrest, eval for “reversible” causes (hyperK, hypoxia, acidosis)
    • If patient severely acidotic and requires intubation, consider ketamine only intubation
      • Fairly low risk, paralyze with scope in to optimize view/tube delivery and minimize apnea time (a bougie may be easier to introduce into cords when patient is spontaneously breathing)
      • Can also consider bagging during induction period (PreVent Trial)
      • Can consider pushing bicarb, but let’s save this can of worms for a future post…
  3. Obtain POC glucose simultaneous to establishing access
  4. Everyone gets an EKG and CXR
  5. RUSH exam if hypotensive
  6. Start with basic airway maneuvers before progressing to intubation
    • If patient is obtunded and unclear if they are protecting their airway:
      • Place C collar if signs of trauma (quick ATLS survey)
      • Perform a jaw thrust
      • Place NPA to stimulate the patient; if tolerating…
      • Attempt to place OPA; if tolerates placement, likely requires intubation for airway protection
        • Gag reflex is absent in up to >1/3 of healthy volunteers (link); don’t rely on this to see if they are “protecting” their airway
  7. Resuscitate before you intubate (i.e. access x2 before intubation in case this hasn’t sunk in yet)
  8. Ketamine is your friend
    • Besides pre-oxygenation, DSI can also be used to position patient who won’t sit still (toxic encephalopathy)
    • If unable to obtain IV access 2/2 agitation and patient is critical, give IM ketamine, then get access
    • As above, consider ketamine-only intubation in severe metabolic acidosis
  9. Two points of access (or one central line) for any patient undergoing RSI; YES you can wait until this is done
    • Overemphasis on RAPID sequence intubation is dangerous
    • Take time to evaluate your access, gather ALL materials and adjuncts, adequately pre-oxygenate and position your patient, discuss plan and roles with the team, etc…
    • If one line fails, you’ll be happy you have a second
  10. Consider A-line placement in any patient undergoing RSI with questionable hemodynamic status
    • If you’ve ever had four people clumsily feeling for a thready pulse wondering if you need to start compressions post-intubation, you’ll understand why this is in here
  11. End-Tidal CO2 is your friend
    • Monitor quality of compressions and ROSC in CPR
    • Confirmation of ETT placement
    • Procedural sedation, OD’s, altered/sedated patients, etc
  12. Do a thorough skin exam (including the perineum) in all DKA patients
    • There have been a few missed cases of Fournier’s gangrene that went to MICU in the past (words of wisdom from my seniors)
  13. Have a high threshold to criticize and a low threshold to praise the EMS crew that hands off the patient
    • They have to do a very tough job with a fraction of our training
    • Sick patients rarely walk into the emergency department, maintaining a welcoming and friendly attitude toward your EMS colleagues ensures we get solid clinical exposure
  14. Take a hands-on approach to managing front room patients:
    • Place landmark-based IV’s with nursing
    • Ask RT how to set up the NIPPV and vents
    • Place your own OG and secure your own ETT after intubating a patient
    • These are skills you may need out in the real world where you’ll have varying levels of resources (that most docs never bother to learn)
    • Your ancillary staff is a wonderful resource for tips and tricks
  15. Per Zoltan Buchwald (class of 2021): “Learn how to be comfortable being uncomfortable.” (see graph below)
    • Sign up for chief complaints that give you that visceral “ugh” feeling
    • Use drugs you’ve never used before (ketamine for induction, haldol for headaches or gastroparesis/acute on chronic abdominal pain, push-dose pressors, phenobarb for AWS, droperidol for anything and everything)
    • Try techniques and procedures you’ve never done before (Nasopharyngoscopy for sore throat/dysphagia, Miller blade, Mac 4 instead of 3 or vice versa, regional anesthesia and nerve blocks)
    • If it’s slow, make yourself busy
      • Do that extra ultrasound
      • Place your own PIVs, draw blood, hang fluids, etc.
      • Run the board and review imaging, labs, vitals of other residents’ patients and physically go and eyeball them
      • Grab students and other junior residents to show them interesting cases, physical exam findings, imaging, ultrasounds, etc

In Summary: 

  1. Every Front Room patient gets two points of peripheral access or one point of central access
  2. Grab a POC VBG on every patient
  3. Grab a POC glucose on every patient
  4. Everyone gets an EKG and CXR
  5. RUSH exam if hypotensive 
  6. Don’t forget basic airway maneuvers
  7. Resuscitate before you intubate
  8. Ketamine is your friend
  9. Ensure adequate access prior to RSI
  10. Consider A-line placement prior to RSI
  11. End-Tidal CO2 is your friend
  12. Do a thorough skin exam (including the perineum) in all DKA patients
  13. Have a high threshold to criticize and a low threshold to praise your EMS colleagues
  14. Take a hands-on approach
  15. Learn how to be comfortable being uncomfortable

Peer Reviewed by: Geoffrey Comp, DO, Jon Kelley, DO, Brendan Tarzia, DO

References:

  1. Brown, N., Kaylene M. Duttchen, and J. W. Caveno. “An evaluation of flow rates of normal saline through peripheral and central venous catheters.” American Society of Anesthesiologists Annual Meeting, Orlando. Anesthesiology. 2008.
  2. Reddick AD, Ronald J, Morrison WG. Intravenous fluid resuscitation: was Poiseuille right? Emerg Med J. 2011;28(3):201-202. doi:10.1136/emj.2009.083485
  3. Ngo AS, Oh JJ, Chen Y, Yong D, Ong ME. Intraosseous vascular access in adults using the EZ-IO in an emergency department. Int J Emerg Med. 2009 Aug 11;2(3):155-60. doi: 10.1007/s12245-009-0116-9. PMID: 20157465; PMCID: PMC2760700.
  4. Casey JD, Janz DR, Russell DW, et al. Bag-Mask Ventilation during Tracheal Intubation of Critically Ill Adults. N Engl J Med. 2019;380(9):811-821. doi:10.1056/NEJMoa1812405
  5. Davies AE, Kidd D, Stone SP, MacMahon J. Pharyngeal sensation and gag reflex in healthy subjects. Lancet. 1995;345(8948):487-488. doi:10.1016/s0140-6736(95)90584-7