Grand Rounds Recap 6.20.18

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Visiting Guest Lecturer: Airway management WITH DR. Richard Levitan

Stress and Performance in Airway Management 

When dealing with hypoxia, anatomy is important. The middle airway, made up of the larynx, trachea, and bronchi is intrinsically patent. The intrinsically patent part of the upper airway is the nares. Positioning of the patient is important to avoid hypoxia, place the patient as upright as possible and preform a jaw thrust maneuver. 

When performing direct laryngoscopy, it is important to elevate the head. Other tips for improving first pass success are to maximize laryngeal exposure, use bimanual laryngoscopy, increase head elevation if needed, and for tube delivery, make the ETT straight to the cuff. 

When trying to overcome vomit in the airway double suction set up can be useful. Consider placing suction to the left of the laryngoscope and then controlling another suction catheter with your right hand. 

Common errors in laryngoscopy are over gripping the laryngoscope. In the setting of an omega epiglottis consider using the Mac blade as a Miller by lifting up the epiglottis.

Tips for the Surgical Airway

Make sure that when you hold the scalpel that you stabilize your hand holding the scalpel on the patient's sternum. Stabilize the larynx from lateral movement with your non dominant hand. 

Small Group Session: Ultrasound APplications WITH DRs. Harrison, Sabedra, and Summers

Ultrasound Guided LP

Considering using this in patients with difficult to identify landmarks and in patients that have had multiple failed attempts. Ultrasound can help to identify the depth needed, angle of insertion, and location of spinous processes. The literature has shown conflicting evidence about if use of ultrasound improves LP success rate, decreases number of attempts, or has improvement in patient comfort.

For a more in depth look check out the most recent Annals of B-Pod issue which features ultrasound guided LP on page 8! When using ultrasound to identify landmarks use the linear probe in the sagittal plane and start by placing the probe over the sacrum. Then move the probe cranially, count the spinous processes. When you identify the interspinous space at the level of interest, place a mark over this area. Then turning the probe in the transverse position mark the location of the spinous process in the midline. Where your lines intersect is where you should attempt the LP. 

Airway Ultrasound

Ultrasound can be used to confirm ETT placement and can be used to help identify landmarks in a cricothyrotomy. Consider ultrasound to confirm ETT placement in situations when EtCO2 is considered less reliable, such as in cardiac arrest, or in resource limited settings. When confirming ETT placement use the linear probe in the transverse plane. The ultrasound probe should be placed in the suprasternal notch. When using ultrasound to confirm ETT placement consider using ultrasound to also evaluation for indirect markers of successful intubation, such as diaphragm movement and lung sliding.

Studies have shown that palpation of the cricothyroid membrane can be inaccurate especially in obese patients. Ultrasound should not be used in the emergent setting, but can be helpful in identifying landmarks prior to intubation in patients with predictors of airway difficultly. Using the linear probe in the sagittal plane start at the midline above the suprasternal notch and slide the probe cranially. The first goal is to identify the trachea which will appear like "pearls on a string". Continuing to move cranially you will visualize the cricoid cartilage and then the thyroid cartilage. The space between these two structures is the cricothyroid membrane. Alternatively, the cricothyroid membrane can also be identified using the linear probe in the transverse plane as described in the ‘"Thyroid cartilage–Airline–Cricoid cartilage– Airline" or TACA method.

Ocular Ultrasound

The retina is located over the posterior part of the globe and is not normally visualized unless there is pathology present. Using the linear probe, placed on an ocular setting, the eye should be evaluated in both the transverse and longitudinal plane.

Optic nerve sheath diameter (ONSD) is a rapid, non invasive technique to evaluate for increased ICP. The optic nerve is best identified in the transverse plane. Once identified, the diameter of the optic nerve sheath should be measured 3mm behind the globe. When the ONSD is greater than 5mm it is suggestive of increased ICP.

Clinical Knowledge: Tuberculosis (TB) WITH DR. Hughes

Identifying TB

Primary TB can present with a variety of symptoms. Cough, hemoptysis, weight loss, chest pain, dyspnea, and night sweats are common ins secondary TB. In the USA the most common risk factor for TB is being foreign born or HIV positive. 

Testing for TB

PPD and quantiferon gold are tests to evaluate for latent TB. When evaluating a PPD it is important to look at induration and not erythema. Patients are considered to have a positive PPD when the area of induration is greater than 5mm in immunocompromised patients and greater than 10mm in health care workers.

Management of TB

Patients should be admitted if they are acutely ill, co-infected with HIV, have MDR-TB, or if a patient is unable to contract for home respiratory isolation. Providers are required to contact the health department for any patient who is being discharged with possible active TB from the Emergency Department. Emergency KT outlines the initial work up for TB in the Emergency Department as well as "hold criteria" for Hamilton Co, Ohio.

Treatment of TB

First line treatment of non-resistant TB can be thought of by using the mnemonic RIPE. RIPE stands for rifampin, pyrazinamide (PZA), ethambutol, and isoniazid (INH). This common medical cocktail used to treat TB has many side effects. Rifampin changes body fluid colors to a red-orange color and can cause liver damage. Pyrazinamide can cause hepatitis and ethambutol can cause optic neuritis. INH causes peripheral neuropathy and is one of the most common causes of drug-induced seizures. In pediatrics INH falls into the "one pill can kill" category. INH metabolites competitively inhibits B6 metabolism which prevents the conversion of glutamate to GABA.  

Clinical Soapbox: PEarls WITH DR. Thompson

Ondasetron

Weight based dosing of zofran, ondansetron, is 0.15mg/kg. In adults 8mg should be the standard, starting dose. It is important to note that zofran is cleared through the liver. In patients with liver dysfunction the max daily dose is 8mg. 

Haloperidol

The evidence has shown that haloperidol has clinical application in patients not just with psychotic symptoms. It can also be considered in patients with gastroparesis, canabannoid hyperemesis syndrome, or migraines.