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Recently, Minh had some questions for James DuCanto on fiberoptics and airway management in general. Here were the questions:

* Some anaesthetists I talk to argue that if you are going to get an optical or video assisted airway device then having it in the same design or functional shape as your traditional devices like the Macintosh laryngoscope, makes more sense than having devices that are of different designs. The Levitan FPS stylet is clearly no Macintosh shape design. What are your thoughts on video laryngoscopes more akin to the traditional Macintosh device like the CMAC versus the Levitan FPS?

* We describe a technique of insertion of an intubating LMA then fibreoptic guided stylet assisted intubation. In what situations have you found this helpful, in your experience?

* In an earlier post you mention having performed a needle cricothyrotomy and rescue jet oxygenation using a dedicated jetting device. It was successful?

* What about ketamine assisted awake intubation?

* How do you intubate through a laryngeal tube airway?

and boy did Jim have answers.

Jim DuCanto is an incredibly prolific anesthesiologist from Wisconsin.

 

Links Mentioned in the Show

* Jim DuCanto's Intubating Videos

* Jim's Guide to the Cookgas

* Reference for Mouth, Screen, Mouth, Screen (Anesth Anal 2007;104:1611)

* My skills of laryngoscopy video

* Seth Manoach Cric-ing a Sheep

* My Awake Intubation Video

Minh Le Cong has a new podcast--check it out to hear a 1-hour Q&A with Jim DuCanto: prehospitalmed.com

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The original ACEP guidelines can be found here.

This table from (Annals of Emergency Medicine  Volume 58, Issue 1, July 2011, Pages 12–20) shows the IUPs eventually discovered on f/u vs. what was seen in the ED at various thresholds of bHCGs.

 What is EMCrit drinking?

Rare Vos by Omegang

Now on to the Podcast:

 

 

 

Hemodynamically unstable pelvic fractures are a talk-and-die situation. These folks require aggressive, rapid treatment if they are going to survive the injury. Inspired by my mentor, Thomas Scalea, I discuss the management of the unstable pelvic trauma patient.

Read these Incredible Posts by Chris Nickson

Part I

Part II

Young-Burgess Shock Trauma Pelvic Fracture Classification

(J Trauma 30(7): 848-856)

from the handbook of fractures

Open Iliac Artery Clamping

Dubose and Inaba (J Trauma. 2010;69: 1507?1514)How to Kill when IntubatingForgot to mention on the podcast--The combination of an open-book pelvis that you have not bound yet and paralytics is a great way to cause massive bleeding. Bind the open pelvis before tubing!!!

New East Pelvic Trauma Guidelines

(J Trauma 2011;71(6):1850)

* external fixation doesn’t limit blood loss, but reduces fracture displacement (III)

* unstable patients should get angio (I)

* pts with blush may require angio even if stable (I)

* ongoing bleeding after angio should get repeat angio (II)

* >60 y/o with major fx should get angio even if stable (II)

* anterior fxs assoc with ant vessel injury and posterior = posterior (III)

* Bilateral non-selective is safe, gluteal ischemia is more likely from injury not angio (III)

* And doesn’t affect male potency (III)

* FAST is insensitive in pelvic trauma (I)–don’t agree with this one

* Adequate Specificity (I)

* DPA is test of choice (II)

* Use CT if stable (II)

* Fracture pattern doesn’t predict need for angio (II)

* Nor hematoma location (II)

* Absence of ICE doesn’t exclude active hemorrhage (II)

* Volume > 500 cm3 predicts need for angio (III)

* Isolated acetabular fx may still need angio (III)

* Perform cystogram after ct (III)

* Binders reduce fx as well as definitive stabilization and decrease pelvic volume (III)

* And they limit hemorrhage (III)

* They work as well or better than external fixation in controlling hemorrhage (III)

* RetroP Packing can be used to salvage after failed angio (III)

* Can be used as primary in an integrated protocol (III)

Can we monitor ETCO2 with extraglottic airways? The answer is definitive--I don't know.

Today, I got to interview Kenji Inaba; an incredibly prolific trauma surgeon from USC/LA County, California. He is the SICU director and surgical critical care fellowship director. If you flip through any issue of the Journal of Trauma, odds are good that Kenji will have an article there.

Here are the questions I got to ask:

From the military studies, 1:1 (PRBCs to FFP) has emerged as the goal during hemostatic resuscitation. The civilian data is less robust, but there are cohort studies out there. Some of them suffer from survival bias and confounding by indication, but enough is out there for most of US trauma centers to attempt to meet the 1:1 goal? What are you folks doing at USC?

This excellent editorial (Resuscitation 82 (2011) 627–628) discusses the problems with 1:1 civilian studies and why we should shoot for this ratio anyway.

What is your transfusion goal with your 1:1. We are giving a mix of PRBC and FFP whenever the patient’s MAP drops below 65 and we don't even bothering looking at the labs to determine which of these two products the patient needs. We are using them just like some saline in the dehydrated patient. If their MAP drops below our goal, they get the PRBC and FFP 1:1 until we get the MAP back up. How about you folks?

For more on this see Rich Dutton's Interview

Where do platelets fit into the mix? At many hospitals they are not available in large amounts and most places are using old platelets and non-type-specific platelets. Some of your own work is on this very subject, should we be matching 1:1 with platelets as well? How about if we only have old, non-type-specific products?

See Kenji's Paper on the topic of old platelets.

Now most of our European and Canadian Colleagues have moved to concentrates instead of FFP and platelets. They use PCCs and fibrinogen concentrates in the initial stages of the hemostatic resuscitation. Is this the future?

 

Are you using TEG or ROTEM, if so how does this fit into the picture? Should it be available in the ED, the OR?

 

Let’s talk TXA. I interviewed Tim Coats, one of the lead authors of Crash 2, last week—he advocates using it with any trauma patient who will need any amount of PRBCs, and to give it as early as possible. I think I agree with him. When are you USC guys giving TXA?

 

MATTERs trial shows that intermittent boluses may be effective rather than starting the infusion. We are giving the 10-minute bolus in the trauma room and then deferring infusion to the STICU if the patient still has active bleeding. Starting an infusion in the trauma bay can be frustrating when we are trying to pour blood products in. How about you?

 

Are you using Rh specific in males? If you give O+ to an Rh - male are you giving rhogam?

This is the AAST Plenary Paper (J Trauma 2012;72(1):48) we mentioned

I am a member of the Kenji fan club; I think you folks will be as well after hearing his sincerity and brilliance.

Welcome to the second episode of Practical Evidence, a podcast about the evidence you NEED to know but may not have time to read.

This month we discuss the American College of Emergency Physicians’ Pulmonary Embolism Clinical Policy(2011)

What’s EMCrit Drinking?

This month, I’m drinking a Dreamweaver by Troeg Brewery

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Please check out our bandwidth sponsor EB Medicine for great offers exclusively for our listeners.

Two studies were mentioned:

Hagihara A, et al. Prehospital Epinephrine Use and Survival Among Patients With Out-of-Hospital Cardiac Arrest. JAMA. 2012;307(11):1161-1168

See Ryan's blog for some great commentary.

&

The PACA Trial: Jacobs et al. Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial. Resuscitation. 2011 Sep;82(9):1138-43.

 

The best lecture on Airway Management--Ever?

Rich Levitan is one of the best teachers on the skills of laryngoscopy--or as he would probably put it, epiglottoscopy. Here is an hour long lecture he delivered last month at Mount Sinai School of Medicine. It is surely one of the best airway lectures I have ever heard.

Want to hear more from Dr. Levitan? Visit his airway site at airwaycam.com.

or, read his incredible book:

Get a big discount on the Emergency Medicine Critical Care Journal

Just go to ebmedicine.net/emcrit

Want the handout?

Here are Rich Levitan's Slides

Audio-Only Version

Right-Click on this Link and Choose Save-as

This episode is eligible for CME

Now, on to the Vodcast...

I am not arrogant enough to believe that I can understand any man's or woman's motivations, so I only argue their words & actions, but I don't force this viewpoint upon any of you. I do ask that you name yourself on any comments, accurately and in a verifiable manner. If you do that I will publish anything you write only editing out curse words for the delicate eyes of my listeners.

This wee was prompted by comments on episode 69.

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