Emergency Medicine – Critical Care – labs

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     1 Resuscitation

1-1 Devices
1-2 Cardiopulmonary resuscitation
1-3 Endotracheal tube

     2 Cardiovascular Anatomy

2-1 Heart – external anatomy
2-2 Heart – valves and chambers
2-3 Aorta
2-4 Pulmonary circulation

 

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       3 Respiratory Anatomy

3-1 Pleural space
3-2 Lung external
3-3 Pulmonary arteries, pulmonary veins, bronchi
3-4 Airway – larynx and trachea

 

       4 Neuroanatomy

4-1 Brain
4-2 Spinal cord
4-3 Meninges
4-4 Skull

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    5 Shock

5-1 Arterial bleeding
5-2 Hemoperitoneum
5-3 Tamponade

 

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   6 Hypertension

6-1 Hypertensive crisis
6-2 Sudden death

 

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     7 Trauma

7-1 Motor vehicle accident
7-2 Head injury
7-3 Fall

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1-1 Devices

1. These cases show external exams with various external devices.

Case 1 Part 1
Case 7 Part 1
Case 11 Part 1
Case 13 Part 1
Case 14 Part 1
Case 33 Part 1
 
a. Identify the devices applied in each case.

b. What is the purpose of each device?

c. Decide if each device appears applied correctly and the correct location.

d. For cases which show EKG leads, decide if application was more likely part of resuscitation or to document the absence of electrical rhythm in a patient who has already died (and could not be resuscitated). (You may need to review the History for the case.)

 

 
 

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1-2 Cardiopulmonary Resuscitation

1. These cases show internal trauma related to resuscitation.

Case 17 Part 3 at 01:40 – 01:48 and 04:37 – end
Case 32 Part 2 at 01:20 – 01:32
Case 39 Part 2 at 01:05 – 01:18
 
a. Where is the trauma in each case?

b. Is it always directly under the site of compressions?

c. How common are rib fractures during chest compression?

d. Do you think the resuscitation caused the death in any of the cases?

e. Would you skip chest compressions out of concern for causing rib fractures?

 

 
 

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1-3 Intubation

 

1. Case 17 Part 6 shows the tracheal placement of an endoctracheal tube.

a. Decided based on available anatomic landmarks where the larynx and carina would likely be.

b. How far above the carina does the tip of the endotracheal tube appear to be?

c. What is the “ideal” position of the endotracheal tube in relation to the carina?

d. When intubating, what steps will you take to ensure correct placement of the endotracheal tube?

1. Case 2 Part 4 shows a traumatic intubation.

a. The emergency provider tried 3 times to intubate with progressively small tubes. How did the trauma occur?

b. Based on the video, why was the patient difficult to intubate?

c. When is it ok to ask for help during a procedure? In general?

d. How many times would you try to intubate (or put in an IV) before asking someone else to try?

 



 
 

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2-1 Heart external

1. These videos illustrate the external heart and have Anatomy Pins:

Case 17 Part 5
Case 28 Part 3 (00:00 – 00:09)

a. Use the Anatomy Pin video to assist. Identify the external structures.

b. Use the Free-Draw sketch pad to make a labelled diagram.

2. This video illustrates the heart and does not have Anatomy Pins:

Case 6 Part 8

a. What structures on the external view of the heart can you identify?

b. Use the Free-Draw sketch pad to make a labelled diagram.

 
 

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2-2 Heart – valves

 
1. View Case 6 Part 9.

a. Identify and name each valve.

b. Identify papillary muscles and chordae tendineae.

c. Be able to identify the direction of flow across the valve and the chamber or vessel on each side of the valve.

d. Identify any coronary artery ostia.

 
2. Use the body map to identify additional videos which show valves.

 
 

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2-3 Aorta

 
1. These videos illustrate the aorta:

Case 1 Part 12 (1:12)
Case 13 Part 7
Case 17 Part 6
Case 39 Part 7

 

a. Identify where you see the aortic root, aortic arch, descending aorta, thoracic aorta and abdominal aorta.

b. Identify the aortic hiatus in the diaphragm.

c. Identify the main branches of the aorta and/or their ostia: right brachiocephalic, left common carotid, left subclavian, celiac, superior mesenteric, renal, inferior mesenteric, and common iliac arteries.

d. Which of these vessels continue directly to their target organ or structure? And which branch into additional named vessels prior to reaching a target organ?

e. If the vessels branch, what are the named branches and their target organs?

f. Once you identify the target organs, name the returning veins from these organs.

 
 

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2-4 Pulmonary circulation

 
1. These cases illustrate the location of the pulmonary trunk:

Case 1 Part 5
Case 12 Part 4
Case 39 Part 3
 
a. Is the pulmonary trunk to the left or right of the aortic root?

b. Is the pulmonary trunk to anterior or posterior to the aortic root?

c. If you were to insert forceps into the pulmonary trunk, you could advance it in three different directions.

i. What directions could you advance your forceps?

ii. Which vessels would you be advancing through in each direction?

iii. And at what main anatomic structure would arrive in each direction?

2. View Case 27 Part 8.

a. Identify the main hilar structures: pulmonary artery, pulmonary veins, mainstem bronchus.

b. Was a pulmonary embolism identified? Was it in a pulmonary artery or vein? Was it a lobar or sublobar vessel?

3. View Case 12 Part 4.

a. Identify the part of the video that shows exploration of the right pulmonary artery (between the pulmonary trunk and the right lung).

b. View the dissection of the pulmonary artery

c. Was a pulmonary embolism identified?

d. Was it within a lobar or sublobar vessel?

e. Which lobe was it in?

 
4. Your patient has a pulmonary embolism in a sublobar pulmonary artery of the right upper lobe of the lung. It originated as a deep venous thrombosis in the left popliteal vein.

a. Trace the path it travelled naming all the vessels and heart chambers along the way.

 
5. View the lung slide in Histology.

a. Identify the pulmonary edema.

i. Where is the pulmonary edema (inside what space)?

ii. What is usually inside this space?

b. Review the pulmonary circulation.

i. Explain how blood gets into and out of the lungs, naming the heart chambers and blood vessels comprising this circulation as they branch down to the capillaries inside the alveolar septae and then back again to the heart.

 
c. Explain why pulmonary edema occurs with left heart failure?

d. Would you expect pulmonary edema to occur in right heart failure?

e. What are diseases that can cause left heart, right heart or biventricular heart failure?

 
 

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3-1 Pleural space

 
1. These cases illustrate the pleural space:

Case 17 Part 4
Case 29 Part 4
Case 30 Part 7
Case 34 Part 2
Case 37 Part 4
Case 39 Part 3 & Case 39 Part 6

a. Evaluate each for pleural fluid and adhesions.

b. For the case(s) with pleural effusions:

i. Are they unilateral or bilateral?

ii. Which side?

iii. Estimate how much fluid is in there.

iv. Is the fluid serous, serosanguinous or hemorrhagic? Exudative or transudative?

v. What might an x-ray show in each patient?

c. For the case(s) with adhesions:

i. What are the adhesions between (example: right upper lobe to chest wall, right middle lobe to mediastinum, etc.)?

ii. Why might they be there (review History)?

2. In this case, the patient had a procedure with instrumentation through the chest wall into the pleural space:

Case 38 Part 5

a. Identify the contusion inside the chest cavity.

b. Decide if the hemorrhage is near the visceral or parietal pleura.

c. Then decide if the hemorrhage is external to the pleura, within the pleura itself, or internal to the pleura.

d. Would you expect hemorrhage inside the pleural cavity related to the procedure?

 
 

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3-2 Lung external

 
1. These cases illustrate the external lung from various perspectives:

Case 1 Part 5 & Case 1 Part 9
Case 11 Part 8
Case 13 Part 8
Case 17 Part 4
Case 14 Part 6
Case 37 Part 4
Case 38 Part 8

a. Before you begin, decide which lobe on each side occupies most of the anterior, posterior, medial and lateral surfaces of each lung.

i. Refer to a diagram if need be.

 
b. For each case, decide when you are looking anterior, posterior, medial or lateral to the organ. Some cases show multiple perspectives.

c. For each case, identify superior and inferior.

d. Identify each visible lobe and each visible fissure.

e. Identify the diaphragmatic surface and lingula, where visible.

f. For Case 1, use the organ block (Part 9) to check if you correctly identified the lobes in situ (Part 5).

g. Decide for each case if there is any anatomic variation, or if the lungs show the usual configuration (3 lobes on the right; 2 lobes on the left).

h. After viewing these cases, reassess your understanding of which lobe on each side occupies most of the anterior, posterior, medial or lateral surface of the lung.

i. Has your understanding changed?

ii. Was your diagram correct?

iii. Is it the same or different in each patient?

iv. How will you apply this knowledge clinically?

 
 

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3-3 Pulmonary arteries, pulmonary veins, bronchi

 
(see Cardiovascular 2-5)

 
 

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3-4 Airway – larynx and trachea

 
1. These cases illustrate the larynx and airway (note, some of these will have Anatomy Pins).

Case 1 Part 6
Case 2 Part 4
Case 13 Part 8
Case 23 Part 2
Case 32 Part 3
 
a. Decide when the view is from anterior, posterior, superior, etc.

b. Which case shows trauma?

i. Where is it?

ii. What caused it?

c. Which case shows pulmonary edema filling the airway?

i. What caused it?

 
d. In which case(s) can you identify the epiglottis?

i. Is it complete or transected?

 
e. Which case shows an anatomic abnormality?

f. Which case(s) might have been difficult to intubate and why?

g. Which cases show identifiable strap muscles?

i. Which strap muscles can you identify?

 
h. Wherever it appears, identify the hyoid bone, laryngeal notch, true vocal cords, false focal cords, posterior tracheal membrane, tracheal rings, and carina.

j. Wherever it appears, identify the cricothyroid membrane (or where it would be located) and the thyrohyoid membrane.

k. Wherever the trachea appears, decide where you would position the tip of an endotracheal tube.

 
 

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4-1 Brain

 
1. These cases show a brain dissection and include Anatomy Pins.

Case 19 Part 5
Case 19 Part 6
 
a. Identify each of the structures using the list of terms beside the Anatomy Pin video.

b. Then scroll-up the list to hide. Now review each pin and be able to identify the structure.

 
2. Case 51 shows a brain dissection (cerebrum) without Anatomy Pins. Try this case after viewing Case 19, above.

Case 51 Part 1
 
a. Use the list of anatomy terms from Case 19 (to the right of the Anatomy Pin video) as a guide for this case (Case 51). Identify as many structures as you can.

b. Groups: Use the Interactive Video to mark up the video.

3. Case 5 is an older case. It shows a brain dissection and includes Anatomy Pins.

Case 5 Part 2
Case 5 Part 3
 
a. Identify each of the structures using the list of terms beside the Anatomy Pin video.

b. Then scroll-up the list to hide. Now review each pin and be able to identify the structure.

4. Check your knowledge with the Self-Assessments: Brain-1 through Brain-3.