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My favorite supraglottic airway is the Cookgas Air-Q; it was created by an anesthesiologist, Dr. Daniel Cook. He just created a new device that allows the placement of an esophageal blocker through the laryngeal airway. I gave him a call to hear about the new product and in the course of that conversation, he gave me a ton of tips on the placement of laryngeal airways. Part II will specifically discuss the new device.

Placement of the ILA

* Put the patient in sniffing position

* Lube it really well (get the bottom, the cuff, and the horizontal ridges up front)

* Dr. Cook recommends an insertion using a tongue depressor to pull the tube forward. He inserts straight back instead of riding the hard palate. If the LMA doesn’t quite turn the corner, he inserts his left index finger just posterior to the tip and flexes his finger to get the LMA to make the curve into the lower pharynx

* He gently advances until the LMA comes to a rest—don’t push too hard

* At this point he puts 4-5 cc of air in for the 4.5 size and 3-4 cc of air for the 3.5 size (same amount of air as the size of the LMA)

Blind Intubation through the ILA

* First step is to lube the inside of the ILA. Use the ET tube itself—put a big glob of lube on the distal portion of the ETT and then advance it until it is just about to pop out of the keyhole opening of the ILA. This distance will be 20 cm in the 4.5 size and 18 cm in the 3.5 size (keep subtracting 2cm for each downsizing)

* Now readvance the ETT to that same point, put your index finger on the top and use it to ever so slowly advance the ET. You can have a hand over the cricoid to feel the ETT as it passes.

* Inflate and confirm by listening over the stomach and looking for End-Tidal CO2.

* If you missed, pull back to that same point that is just before the opening of the cuff and inflate the ETT cuff with 1-2 cc of air. You can now reoxygenate the patient before your next attempt.

* The second attempt should probably be with a fiberoptic device or a bougie.

Bougie Intubation through the ILA

* First lube the ILA using the ETT, then remove the ETT

* Advance the bougie using the coude end with the coude facing towards the ceiling.

 

Here is the podcast:

Today, I got to interview Dr. Stephen Smith. Dr. Smith is faculty at the Hennepin Program and author of one of the best books on EKGs in the ED, The ECG in Acute MI.

Dr. Smith's EKG Blog is probably the best free EKG site out there for Emergency Physicians and Intensivists.

Here are the points we covered:

1. Ischemia Doesn't Localize

If you see depressions in just one anatomic area, think reciprocal changes to subtle ST-elevations elsewhere

2. If you see Inferior Depressions, think High Lateral Wall STEMI

here are two good cases from Dr. Smith's Blog:

* Case: This is a 35 yo woman who had LAD occlusion that was very subtle on ECG, but easily seen with inferior ST depression

* Case: This is one of a high lateral MI due to OM-2 occlusion that shows up mostly with inferior ST depression.

3. Lateral Wall STEMIs are often Subtle

* Case: A patient had chest pain, went to his doctor who did an EKG, said it was fine, and sent my friend home. He had a cardiac arrest at home and was resuscitated because of good CPR by his wife.  Later, I asked him to find the ECG.  I told him I’m pretty sure it was not normal.  And here it is: a very subtle high lateral MI detected by subtle ST depression in II and aVF

* Another Case

4. Absolute millimeter criteria for STEMI will often fail you, it is the Pattern that Matters.

5. Benign Early Repolarization and LAD Occlusion can look very similar--You may need to do the math.

Dr. Smith derived this formula:

(1.196 x STE60 in V3 in mm) + (0.059 x computerized QTc in milliseconds) - (0.326 x RA in V4 in mm),

where RA is R-wave amplitude and STE60 is ST elevation at 60ms after the J-point relative to the PR interval.

If the value of the formula is greater than or equal to 23.4, it is MI (Sens, spec, accuracy all around 90%); if less, then it's early repolarization.

* Case: Here is a case that illustrates this, it shows a very subtle anterior STEMI, and how use of the complicated new rule that he developed. One need not use the complicated rule; among other  features, it was the long QTc of 455ms that made it unlikely to be normal.   The followup ECG is also very instructive.

You can also see a video of the concept

6. If you are calling it BER, there need to be R waves in the Precordial Leads

7. Q-waves can develop instantly after a STEMI

qR waves can develop instantly and are not indicative of poor response to lytics or PCI (J Am Coll Cardiol 1995;25:1084); this concept is not  applicable to a QS pattern.

8. If you see a wide (>190 ms) QRS, think Hyperkalemia

9. The treatment for VT with hyper-K is Calcium, Calcium, Calcium

* Check out this Case, it says it all

10. Check Out these Two Other Great Sites

HQMEDED: High Quality Medical Education and Ultrasound

The Prehospital 12-lead ECG Blog which despite the name,

I was able to cajole Cliff Reid of the amazing blog, resus.me on to the EMCrit program. Cliff is truly a doc after my own heart as you will hear from the cast.

He is currently an EMS physician and Director of Training at the New South Wales Ambulance Service.

Cliff's blog, resus.me is an incredible collection of timely articles on emergency medicine, ems, critical care and resuscitation.

Cliff mentions the HEMS service in London. This amazing service sends a physician/paramedic team to the scenes of bad traumas by helicopter and response cars. A well done video is available on youtube:

http://www.youtube.com/watch?v=G0EENc_zNR0

The winner of the Toxicology Handbook is Jenny Mendelson. Yeah!!!

photo by Mad Scientist

Click Here to Play the Podcast

This is the DSI Podcast. If you want all of the great DSI information, please come to the EMCrit Delayed Sequence Intubation (DSI) Page

 

 

Hmm… he’s tasty, but he just needs a little salt

In this podcast, I discuss the management of hyponatremia in the ED. After reading countless articles from the nephrology literature…I can still attest that I have not a friggin’ clue about renal physiology. But I think I have found a simpler path to the work-up and treatment of low sodium in the ED.

When they are <130 is when I get a little worried

Step I-Send Lots of Labs

Here is what you need:

Serum-electrolytes, LFTs, osmolality, uric acid (if on diuretics), and you might as well send a TSH and cortisol as well (if you have any suspicion of an endocrine cause)

Urine-UA, urine lytes, urine urea, urine uric acid (if on diuretics), urine osm, urine creatinine

Want to learn more about FENa and FEUrea? Well I have an article for you.

Step II-Treat CNS dysfunction

If the patient is altered, comatose, seizing, or has neurologic findings, then raise the sodium by a little bit

Give 3% saline, 100 ml over 10-60 minutes (2 cc/kg up to a max of 100 cc)

10 minutes later, may repeat X 1

may be given peripherally through any reasonable IV

each 100 ml will raise sodium by ~2 mmol/l

Step III-Hang tight

Do not feel the need to do anything else, just fluid restrict the patient

Place a foley

Do not feel tempted to give NS

Do not be clever, just fluid restrict and admit.

Patients are at a fall risk with hyponatremia

Get a CT scan if they are still a little wacky

Remember the rules of 6’s (from the Stern article below)

Be incredibly careful when correcting hypokalemia, potassium repletion will raise the Na

Step IV-What to do when you couldn’t follow step III

dDAVP 1-2 mcg IV or SubQ x 1

Consult renal

Consider D5W 6ml/kg over 1 hour in consultation with renal if you have really screwed up

For more on this, see the Emergency Pharm D Blog

Additional Info

Drugs-Thiazides, SSRI, Sufonylureas, Opioids

1 liter of saline will allow a solute-low hyponatremia to make 6 L of urine

SIADH-need to get rid of a 600 mmol salt load/day. Can fluid restrict to 900 ml (400 insensible).

Articles

Read this excellent case report from Stern

Excellent Review by Schrier (Curr Opin Crit Care 2008;14:627)

Review of Drug-Induced Hyponatremia (Am J Kidney Dis 2008;52:144)

Understanding Lab Testing for Hyponatremia (Clin J Am Soc Nephrol 2008;3:1175)

The hyponatremia formulas do not work so well (Clin J Am Soc Nephrol 2007;2:1110 and Nephrol Dial Transplant 2006;21:1564)

Fantastic Review Article on Hyponatremia and SIADH

Here are my 12 favorite ED Critical Care things for 2010...the EMCrit Dirty Dozen:

12. SmartEM by David Newman and Ashley Shreves

11. The Poison Review by Leon Gussow

10. Academic Life in Emergency Medicine by Michelle Lin

9. Zdoggmd--the funniest internist I have ever come across

8. Emergency Medicine Cases Podcast by Anton Helman

7. One Night in the ED, an incredible radiology blog for EM folks by a radiologist, Daniel Cornfeld

6. Steve Smith's EKG Blog-even the cardiologists are not giving the same amount of detail as you will find here

5. Resus.me by Cliff Reid

4. EM:RAP by med ed hero, Mel Herbert

3. Ercast by my friend, Rob Orman

2. the Life in the Fast Lane Blog headed up by the amazing Mike Cadogan and Chris Nickson

1. Well for #1, you are just going to have to listen

Want more Best of?

* Eight is Enough for 2013

* Natural Seven for 2012

* Hard Six for 2011

When an ED starts providing advanced care for severe sepsis, lactate testing is an absolute requirement. Lactate use brings up a lot of questions, especially if it is not commonly ordered in your department. In this podcast, I discuss all of the lactate questions that have come up in the course of the NYC Sepsis Collaborative.

For the past few months, I have been co-chairing this NYC-wide sepsis collaborative under the auspices of a hospital organization. 56 hospitals have joined the collaborative with the goal of breaking down the barriers to aggressive sepsis care in the ED.

The protocols and educational materials for the project will always be cross-posted here:

http://emcrit.org/sepsis/

Many of the questions we have been getting relate to the use of lactate as a screen and an indicator of adequate treatment. Last week, I discussed these issues during a webinar. This podcast is the recording of that cast.

Here is the Lactate Reference Sheet

Other important info:

The emcrit webtext is now at crashingpatient.com and the blog has moved to http://emcrit.org

Scott Gallagher sent in the comment regarding commotio cordis as a cause of v-fib/v-tach in trauma patients. He is quite right to point out that ACLS works for these folks. Shock and use anti-dysrhythmics.

Here is a reference from the New England Journal:

NEJM 2010;362:917

Update:

Another article demonstrating the equivalence of arterial and venous lactates (The American Journal of Emergency Medicine  Volume 31, Issue 7, July 2013, Pages 1118–1120)

A review by some of the Lactate Doubters

A balanced perspective on lactate from NEJM [cite source='pubmed']25494270[/cite]

Another article demonstrating the >=4.0 threshold is a good one (10.1097/CCM.0000000000000742)

A small study demonstrates that venous lactate may be even a better prognostic predictor than arterial (Effectiveness of arterial, venous, and capillary blood lactate as a sepsis triage tool in ED patients. Am J Emerg Med. 2014 doi: 10.1016/j.ajem.2014.11.003)

Thanks to a suggestion from Melanie, this week I am discussing the management of traumatic arrest. Many things to do in these patients, but two things you definitely should not be doing are closed-chest CPR or giving ACLS medications. We discuss who gets a thoracotomy, what to do if a thoracotomy is not indicated, and when to stop.

Here is a great review article:

Hunt PA, Greaves I, Owens WA.  Emergency thoracotomy in thoracic trauma-a review. Injury. 2006 Jan;37(1):1-19.

This is one of the figures from the text. I think it is a great algorithm to determine who gets a thoracotomy:

From Hunt et al. Injury 2006;37:1

Update: This article lends further support that all patients should have tension pneumo excluded (Resus 2007;75:276)

Place comments or questions here or on the facebook page at facebook.com/emcrit.

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In this podcast, I discuss extubating patients in the ED. Specifically, I deal with patients who have only been intubated for a few hours in distinction to extubation of the patient who has been lingering in your ED for 2-3 days. The best patients for this short-term extubation are those intox folks with a low GCS and signs of trauma, overdoses, or endoscopy cases.

My approach is outlined in this article; click on the link for the full text:

Weingart SD, Menaker J, et al. Trauma Patients Can Safely Be Extubated in the Emergency Department. J Emerg Med. 2009 Aug 22. [Epub ahead of print]

Here are the steps from the article:

Photo by EddieB55

Update

* George Douros has written another excellent guideline for ED extubation.

* Sara Gray has also done a swell job discussing Sara Gray-ED Extubation

* Newest study from UMich (West J Emerg Med. 2020 May; 21(3): 532–537. )

More on Extubation from the EMCrit Crew

* PulmCrit Wee – The meaning of nocturnal extubation is 42

* High-flow nasal cannula to prevent post-extubation respiratory failure

Now on to the Podcast...

The brand new ACLS & BCLS guidelines were published last week. Not huge changes, but some good stuff! The free full text is available at the Circulation website. It takes hours to make your way through all of it. I boiled it down to just the facts and posted a summary on the Crashing Patient Site.

ACLS 2010 Guidelines Summary

In this EMCrit Podcast I discuss some of the highlights that I think are particularly important.

There have also been many questions about the head impulse testing discussed in episode 33. I have an easier method; check out this post.