Intubating (not in the SRU)

Intubating (not in the SRU)

Logistics are pretty much everything.  A focus on logistics is what helps UPS deliver 500,000,000 during the holiday season.  A focus on logistics is what helped the Allies win World War II.  But logistics doesn’t just happen on the global, macroscopic scale.  Logistics plays a role in every procedure we do in the ED and in the prehospital environment.  If you only focus on learning the mechanics of physically performing a procedure, you are neglecting crucial steps that will help ensure your success.  In this our latest podcast in the Air Care and Mobile Care Online Flight MD Orientation, Dr. Steuerwald and Dr Hill discuss some of the complicating factors for prehospital airways, focusing on both some of the logistical issues that come into play and some of the mechanical/physical considerations.

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So You Want to Tomahawk Somebody?

So You Want to Tomahawk Somebody?

If you took a listen to our last podcast or inferred from our most recent post, the "challenging airway" that was described was managed by way of a tomahawk intubation.  As we discussed in the podcast, there were a number of different ways we could have elected to manage that patient's airway including intubation from the back of the stretcher with the patient seated upright, awake fiberoptic intubation (both nasotracheal and oropharyngeal with the assistance of a Williams airway), tomahawk intubation, or, as was suggested by one of the residents (nice suggestion Dr. Cousar) after our simulation (on the same case), through a bronch adapter hooked to a LMA...

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What Makes an Airway Difficult

What Makes an Airway Difficult

What Makes an Airway Difficult? In short, a lot of different factors play into making an airway difficult.  In general, they can be broken down into anatomicphysiologic, and logistic.  We'll cover some of the logistical issues that can complicate intubations on a later post (mostly with regards to intubation in the HEMS and prehospital  setting).

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Oxygen is Good, Methods for Delivery Often are Not

Oxygen is Good, Methods for Delivery Often are Not

An elderly patient with steroid and oxygen dependent COPD, and NYHA Class IV CHF, presents with dyspnea.  The patient is alert but looks somewhat desperate, confused, and exhausted.  Exam reveals accessory muscle use, grunting expirations, poor air movement, and cool clammy skin.  The patient speaks in two-word phrases.  Attempts to improve the situation are made with Lasix, nebulizers, and non-invasive ventilatory support.  The patient cannot tolerate BiPAP due to anxiety.

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Pericardiocentesis

Pericardiocentesis

First, pericardiocentesis should be considered a temporizing procedure.  In the setting of trauma, you are hoping that the pericardiocentesis will clear a small amount of blood from the pericardial space and remove any tamponade the might be present.  It is likely, however, because of the mechanism of injury, that blood will again rapidly accumulate leading to recurrent tamponade physiology.  Ultimately (but not on Air Care — DON’T do a clamshell), these patients will need a pericardial window, exploration, and repair of whatever injury is causing the accumulation of blood. 

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Look Before You Leap - Awake Fiberoptic Intubation

Look Before You Leap - Awake Fiberoptic Intubation

Look Before You Leap, Drive Your Ferrari Like it is a Wheelchair, Harken Ye to the Wicked Witch of the West!

A 37 year-old woman presents with stridor, drooling, tachypnea and accessory respiratory muscle use.  She has an adequate blood pressure, but is tachycardic to 120.  Her oxygen saturation on room air is a reassuring 97%.  She cannot answer questions, appears to have an altered mental status though she follows commands, and suddenly has a brief period of either myoclonus or seizure with unresponsiveness.  No post-ictal period is noted after this episode.

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Awake Fiberoptic Intubation

Awake Fiberoptic Intubation

Like all procedures, success in the performance of an awake fiberoptic intubation comes from proper preparation.  Preparation for this procedure means so much more than proper preparation of the patient (preoxygenation, positioning, local anesthesia, etc.).  To be fully prepared is to have a well practiced, working knowledge of your equipment and the options you have in setting it up.  To be fully prepared is to be practiced in the motor skills necessary to drive the scope, advance the tube and troubleshoot as you go.

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Finger Thoracostomy

Finger Thoracostomy

We talked about needle thoracostomy a while back and when we did, we talked about the propensity for the needle to fail.  There are a lot of reasons why the needle could fail to relieve a tension pneumothorax (or to only temporarily relieve a tension pneumothorax).  The needle may be too short to enter the thorax in the first place* or the catheter could kink, allowing reaccumulation of air in the thorax.

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The Decision to Intubate

The Decision to Intubate

The I.C. Cordes College of Airway Knowledge, written by Dr. Steven Carleton, is known to many who have passed through our doors.  Today, however, we begin to set them free to the #FOAMed world starting off with I.C. Cordes #1 - The Decision to Intubate.  I felt like I had found a mint copy of the Amazing Fantasy Introducing Spiderman comic book or a Honus Wagner baseball card receiving these collected cases by email from Dr. Carleton earlier today. - Jeffery Hill, MD

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Application of Pelvic Binders

Application of Pelvic Binders

As we mentioned in the podcast that accompanied our most recent post, an injury that is critical to identify in blunt trauma yet easy to miss or forget is pelvic fractures and pelvic trauma.  Significant injuries occurring to the pelvic ring usually involved high mechanisms of injury such as high speed MVCs, motorcycle crashes, pedestrian struck, and falls from significant height.  Pelvic fractures can be associated with a significant amount of bleeding, hypotension, and increased mortality.  Mortality for all trauma patients with pelvic trauma ranges from 5-30%.  If there is associated hypotension, mortality rises to 10-42%

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On Tourniquets and Lives Saved

On Tourniquets and Lives Saved

Though tourniquets were likely in use since Roman times, the term “tourniquet” was originally turned by Louis Petit, the 18th century inventor of the screw tourniquet.  Though numerous design advancements have occurred and new devices have been made in the centuries that have followed, the basic principles of tourniquet use are essentially unchanged.  A tourniquet applies an external pressure to a limb (usually) that exceeds the arterial pressure in that extremity.  In this way the inflow of arterial blood to an extremity is stopped.  For a surgeon, in the setting of a prospective extremity surgery, this allows for the creation of a bloodless operative field.  For Emergency Medicine providers, tourniquets can aid in the exploration of extremity wounds, allowing the identification of injuries to tendons, joints, and vascular structures.  And perhaps most importantly, tourniquets applied proximal to the site of penetrating traumatic extremity injuries can cease bleeding from arterial injuries.

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Trouble with Trachs - Recannulating the Stenosed Trach Site

Trouble with Trachs - Recannulating the Stenosed Trach Site

TracheOTOMY sites can close up rapidly (within hours).  Why is this?  Essentially, there is (usually) no missing tissue with this procedure.  Occasionally the procedure does involve cutting a small section of the tracheal ring out but this is much less common now that percutaneous techniques are more in vogue  The percutaneous technique involves, essentially, dilation of the skin, soft tissue, and trachea and, as such, these sites can close up very rapidly.

TracheOSTOMYsites are less of of problem as they do involve the removal of tissue.  If they are fresh, however, these sites can also close relatively quickly.

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Transvenous Pacemaker Insertion - Part 3

Transvenous Pacemaker Insertion - Part 3

We used Part 1 and Part 2 in this series to give you an in depth understanding of all the critical steps of the procedure.  After reading those posts you should have a good grasp of the indications for the procedure, the complications you may encounter, and you will have read, seen, and heard step by step instructions for placing a transvenous pacemaker in the ED. This final installment in the series should bring it all together for you.  Here you will see the placement of the transvenous pacemaker from start to finish from the point of view of the operator (Dr. J'Mir Cousar) all filmed in glorious HD.

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Transvenous Pacemaker: Part 2 - A Procedural Slide Set

Transvenous Pacemaker: Part 2 - A Procedural Slide Set

worked to create a video walkthrough of the procedure.  The video walkthrough is divided into two separate videos.  The first, embedded below is a narrated procedural slide set, designed to be a cognitively unloaded approach to learning the procedure.  In a later post we'll see a full, start to finish video of the procedure filmed from the first person viewpoint.

In addition to the video being posted here, Dr. Cousar has constructed a checklist that will be placed on the pacemaker generator which will have a QR code to link to this narrated slide set.

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Transvenous Pacemaker Placement - Part 1: The Walkthrough

Transvenous Pacemaker Placement - Part 1: The Walkthrough

If you are interested in seeing the placement of a Transvenous Pacemaker after reading this post check out Part 2 (Procedural Slide Set) and Part 3 (the first person view of the procedure)

Reasons to Pace in the First Place

Hemodynamically unstable+

1. Sinus Bradycardia - seen in 17% of acute MI patients (especially inferior or anterior wall MI) [1,2]

2. AV Block - may be due to ischemia (15-19% of all Acute MI) [2,3]

3. Drug Overdose - with the goal of maintaining adequate hemodynamics while your medical therapy/dialysis has an opportunity to work.

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