Grand Rounds Recap 9.6.23
/ultrasound grand rounds: bedside dvt studies - family presence in the ed/icu - r1 clinical knowledge: aicd - r3 small groups: difficult airway management
Ultrasound grand rounds: DVT studies WITH Dr. minges
Why should we perform bedside DVT studies in the ED?
Limited availability of radiology-performed US services in certain hospitals, especially overnight
Can avoid unnecessary anticoagulation in patients
Reduce time in ED to disposition
In terms of workflow, when there is suspicion for a DVT, you need to first calculate a Wells’ Score for a DVT
If low/moderate risk, can start with a D-dimer prior to committing to a DVT study
If high risk, can go directly to a DVT study
The bedside DVT protocol in the our Emergency Department
Typically use a linear probe
Yet, can use curvilinear if vessels are found to be deeper than expected
Goal is to find the landmarks noted below and apply pressure to ensure the vessel fully compresses at each site
First find saphenofemoral junction (SFJ)
Then move the probe proximally to find the Common Femoral Vein (CFV) & start your compressions there
Move back down to the SFJ
Attempt to compress the Common Femoral Vein (CFV) and Greater Saphenous Vein (GSV)
Look 1-2cm along the GSV as well, as these are still clinically important and can actually lead to a PE
Continue compressing distally and look for the division between the Femoral Vein (FV) and Deep Femoral Vein (DFV)
Typically looks like a snowman
Follow FV down thigh and continue to attempt to compress every few centimeters
Go down to the Popliteal Vein (PV)
This is a low pressure vein, so be mindful of the amount of pressure you apply
Typically find it just above the pulsating popliteal artery
Move down and find the popliteal trifurcation
Sometimes there are some anatomical variations, such as a bifurcation being present instead
Family Presence in the ED and critical care WITH dr. kreitzer
Field of pediatrics and neonatally pioneered family presence at the patient’s bedside
Family presence during CPR/procedures
Families benefit most by being present during resuscitation or CPR
Report a sense of control, closure, and improved understanding of loved one’s condition
There was a randomized control study published in NEJM (Jabre, et al., 2013)
In this study, family members were invited to observe CPR compared to a control group
79% witnessed CPR (compared to 43% in the control group)
PTSD rates, as well as anxiety and depression, were all higher in control group, compared to group invited to witnessed CPR
Yet, there were no changes in resuscitation outcomes, including patient survival rates, despite presence of family members
So why don’t we have more families at the bedside?
Providers are worried that families will interfere with patient care
Also worried that the psychological burden would be too high for family members
Family centered model can typically benefit patients
Reduced length of ICU stay
Reduced patient’s & family member’s anxiety, stress
Nonetheless, can also increase risk of infection transmission
Family centered model can typical benefit providers as well
Family members can supply additional pertinent history
Relatives can acutely notice clinical changes in their loved ones
If family is present during rounding, this will actually reduce family meetings outside of rounds
Yet it can have drawbacks to providers as well
Nursing staff report increase in workload, as they have to support and educate family members, as well as the patient themselves
Increases rounding time, while also reducing the educational discussions during rounds
May reduce the delivery of valid, yet negative information during rounds
What can you do on your ED or ICU shifts to make experiences better for patients and their families?
Overall, need to think about ways that might reduce anxiety, depressive symptoms, or PTSD (rather than just patient satisfaction)
When speaking with families, try to identify one family member as a representative
Initial information to families should include information about the hospital, ICU, visiting hours, how a provider can be reached
Noise in the care environment should be reduced
Encourage the start of a diary or journal
If family members choose to be present for procedures, healthcare professionals need to recognize the complexity of emotions and adequately prepare for them
Clinicians must take precautions to make sure that bedside presence is comfortable and safe for families
Encourage family to be present during rounds and family meetings
Family meetings should be multidisciplinary and include nursing staff
Family meeting should occur 24-48 hours after admission and repeated as necessary
Address a family member’s emotional needs and provide resources for coping during these meetings
Organizations should aim to:
Provide support to nursing staff who are expected to engage in family centered care
Have protocols and education for families regarding infection control, ED and ICU process, and regulations
Train staff to assess family needs, be consistent, and provide regular updates in accessible language, and in a variety of formats.
Provide support staff such as social work, clergy, and potentially support groups
r1 clinical knowledge: AICD WITH dr. onuzuruike
AICDs shock when detecting V tach or V fib
assuming the device is functioning properly and correctly identifying a malignant, ventricular rhythm
Magnets turn off defibrillating features
yet pacing function will remain intact
History, physical, and labs help with disposition
Stable patients can either go home or be observed overnight
Unstable patients will typically require consult and admission
r3 small groups: difficult airway management WITH drs. negron & wright
Assess for a difficult airway using the LEMON mnemonic
L - Look for concerning external features (facial swelling, trauma, dentures, C spine immobilization)
E - Evaluate with 3-3-2 rule for mouth opening and larynx positioning (3 finger breadths mouth opening, 3 finger breadths hymenal distance, 2 finger breadths thyrohyoid distance)
M - Mallampati score (oral airway accessibility)
O - Obstruction and obesity (tongue swelling, masses, burns, body habitus)
N - Neck mobility (C collar, extreme kyphosis)
Management of a Difficulty Airway
Impending Need for Intubation
Pre-oxygenate, ETCO2
Determine RSI safety, address hemodynamics
Optimize positioning
Plan A, B, C for airway
Evaluate need for awake intubation
Difficult airway equipment nearby (SGA, bougie, intubation adjuncts)
Surgical airway equipment backup
Know who to call and how if you fail
Immediate Need for Intubation
Optimize first attempt as noted above
Have variety of adjuncts readily available
Video-laryngoscopy to aid visualization
Bougie to facilitate passage if poor visualization
Aintree for iGel exchange
Consider short acting NMJ blocker
Failed Intubation
Declare a failed intubation
BVM between attempts
Intubation adjuncts
Make subsequent attempt(s) different
Consult airway back up (ex. ENT) if needed
Cannot Intubate Cannot Ventilate (CICV) Scenario
If unable to intubate and have lost ability to ventilate, declare CICV scenario
Attempt surgical airway
Consult airway back up
CASE 1: Inhalation injury
Suspect when enclosed in fire/smoke
Facial burns, singed hair, soot in face or airway
Look for red flags: stridor, dysphonia, extensive burns
Consider an “Awake look” with sedative (yet no paralytic)
considering preloading ETT
especially if any red flags present
In concomitant trauma with ability to access oropharynx with acceptable Mallampati score and other indications for intubation (head trauma, AMS in our case), oral approach reasonable with video-laryngoscopy preferred
CASE 2: Foreign Body Aspiration
Consider position of foreign body (complete vs partial obstruction)
In patient undergoing CPR; look with video-laryngoscopy
Utilize Magill forceps for supraglottic visualized foreign bodies
If difficult to reach, code situation, or CICV scenario, consider mainstream intubation to force the foreign body to right mainstem, then retract ETT to normal positioning and ventilate
CASE 3: Angioedema
Prep fiberoptic scope and materials: ETT, 10 cc syringe, jelly, nasal trumpet, ETCO2, securing supplies
Patient prep: Upright, head slight extension, pre-oxygenation via NRB, glycopyrrolate, zofran, afrin, mucosal atomizer with 4% lidocaine, viscous lidocaine
Medications: consider ketamine, propofol, or a combination of both
Scope through slit nasal trumpet (so nasal trumpet can then be removed)
Or, alternatively can subtotally intubate with ETT in the nare and scope through ETT
CASE 4: Facial Trauma
Optimize first attempt considering possible obstruction based on fractures, edema and initial LEMON assessment
Suction set-up is key
Consider direct laryngoscopy although VL with DL back up very reasonable, especially with C spine immobilization
CASE 5: Intubating Through an iGel Device
Patient’s hemodynamics and predictors of a difficult airway may limit ability to successfully remove pre-hospital a iGel device and allow intubation attempt
In this case, you can actually intubate through the iGel itself
Two-Tube Technique:
For a size 4 iGel, preload a 7.0 ETT onto a fiberoptic scope.
Lubricate fiberoptic scope and 7.0 ETT.
Pre-load the 7.0 ETT onto fiberoptic scope.
Scope through the iGel to the level of the carina.
Feed ETT over scope.
Remove scope, noting level above carina as you withdraw past ETT. Inflate balloon.
Remove BVM adaptor from ETT and fit with end of 6.5 or 6.0 ETT, also with its BVM adaptor removed.
Remove iGel over the extended/attached ETTs, taking care not to dislodge ETT from position and disconnecting the two tubes when able.
Reattach BVM adaptor.
Aintree Technique:
Attach bronchoscopy adaptor to iGel and continue bagging.
Lubricate fiberoptic scope, 7.0 ETT, and Aintree catheter.
Feed Aintree catheter onto fiberoptic scope, securing it to base of scope with a small piece of tape.
Insert scope with Aintree overtop through the adaptor while assistant/RT continues to bag. Identify and advance to carina.
Pass Aintree catheter over scope. Remove scope.
Remove iGel (and adaptor) over the Aintree catheter, taking care to not allow catheter to become dislodged. Note that you may attach adaptor to Aintree to try to oxygenate here if sats drop, but unlikely to offer much in terms of oxygenation.
Intubate over the Aintree as you would a bougie. You may use VL to attempt to visualize tube through cords.
