Video Laryngoscopy in the Field? Absolutely

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Video Laryngoscopy in the Field? Absolutely

Close your eyes... actually open them up, you won't be able to read the description if you close your eyes... Imagine you are on flying on the helicopter for a scene flight.  You land and are brought to the patient, a victim of a motorcycle accident who is clearly in need of an airway.  He is obtunded with sonorous respirations, a GCS of 6, O2 sats in the low 90's.  You start to look and assess the patient's airway and you are decidedly less than pleased.

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Rescue Me

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Rescue Me

Extraglottic devices are often term "rescue devices."  And I can't decide whether this is a term that glorifies or degrades.  While yes they can often save your tail after a failed attempt at direct or video laryngoscopy, they can do so much more. Running a code in a resource limited setting with 2 providers? The gold standard of 2 person bag valve mask technique ain't going to be an option for you.  And you think you can hold C-E mask seal while bagging for 20 min?  If you can, you must have hands that rival the late great Andre Rene Roussimoff...

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Decision is a Sharp Knife

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Decision is a Sharp Knife

In emergency medicine, EMS, and critical care transport medicine, I think we’d all (at least secretly) agree that there’s absolutely no greater joy than being able to say to ourselves, “That guy (or lady) is still walking the earth because of the care my team and I were able to give him (or her).”  I’m talking about the sort of patient that you bring back from the very brink of death with knowledge and skill borne of hard work and practice.

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Needle Cricothyrotomy

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Needle Cricothyrotomy

Circumstances rarely are such where we must perform a surgical airway emergently. When we do, it is always for the same indication: you have a patient that you can’t intubate AND can’t oxygenate. In most cases where a surgical airway is required, a traditional open or Seldinger technique is preferred.

In children, however, these approaches are contraindicated (most authors describe age less than 10 or so as the cut-off). Thus, the needle cricothyrotomy is a procedure that we must be prepared to perform as emergency providers as this can be done in pediatric patients.

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Intubating (not in the SRU)

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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?

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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

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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 anatomic, physiologic, 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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The Levy Cup Cometh...

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The Levy Cup Cometh...

On this day of #EMConf goodness, we tease the upcoming day of Grand Rounds competition known as The Levy Cup.  In 3 weeks time, the residents will pair off into teams in a battle of wits and skills.  A round robin competition of procedural relay stations, simulations, trivia game shows, Cash for Cases (where the less money you spend on the patient, the more points you get) and some surprises I don't want to spoil here will pair the field down to 2 teams that will compete in the finale.  Think SimWars gone crazy!

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Oxygen is Good, Methods for Delivery Often are Not

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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

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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

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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

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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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Lessons in Transport - Plasma? We Got That...

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Lessons in Transport - Plasma? We Got That...

Why is Air Care starting to transport and infuse plasma? Multiple studies, many from military combat zones, strongly suggest that clinical outcomes are improved by administration of plasma alongside RBCs in a 1:1 ratio. (1,2) Furthermore, the concept of damage control resuscitation advocates for minimizing crystalloid infusion and maximizing early aggressive resuscitation with blood products in patients with life threatening hemorrhage. Recent unpublished analysis suggests that expanding these resuscitation principles to the prehospital environment via helicopter EMS was associated with improved outcomes.

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Lessons in Transport - Your Friend and the Bleeding Patient's Friend: TXA in trauma

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Lessons in Transport - Your Friend and the Bleeding Patient's Friend: TXA in trauma

TXA… What can be said about TXA that hasn’t already been said.  TXA is good for what ails you.

Nosebleed? No problem.

Menorrhagia? TXA can fix that.

Involved in a motor vehicle crash with multiple pelvic fractures, a busted up spleen, hemorrhaging internally? TXA has your back.

In this podcast, Dr. Hill, Dr. Steuerwald, and Dr. Gerecht sit down and talk through the indications for using TXA in the prehospital environment and briefly discuss some of the evidence for its use.

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Lessons in Transport - Cognitive Biases in Critical Care Transport

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Lessons in Transport - Cognitive Biases in Critical Care Transport

As critical care transport professionals we are often perceived as an action oriented specialty. We frequently pride ourselves on procedural excellence and efficiency. (a difficult intubation, or fast scene-time etc.) However, the reality is that we spend the vast majority of our patient care time engaged in cognitive behavior... in THINKING rather than acting!

Because of this, it is imperative that we make every possible effort to understand how we think while caring for others. In addition, we should be aware of some of the cognitive biases that threaten our thinking processes, decision making, and thus the patients who place their trust in us.

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