EMCrit FOAM Feed

Darren Braude, Aiway and EMS master from New Mexico demonstrates the use of a bougie to make the cric procedure MUCH easier. For more great Braude magic, see his site at airway911.com.

 

http://www.youtube.com/watch?v=wVQFJR7qmrQ

 

 

This is a video by my friend Seth Manoach, MD. He has been an EM Physician for many years and now is in the midst of a three year critical care fellowship sojourn.

This video demonstrates the fiberoptic stylet-aided cric. In this case he is using a Levitan Scope, but an adult bonfils or any other rigid fiberoptic should work fine.

The airway he is using is the Melker cuffed cric catheter, but I have tried this in trach incisions with 6-0 ET tubes, and 6.0 trach tubes as well.

Here is the article seth put in the literature:

Resuscitation. 2009 Sep;80(9):1066-9.  Development of a rapid, safe, fiber-optic guided, single-incision cricothyrotomy using a large ovine model: a pilot study.

Please note: The sheep in this video was treated with the utmost respect and ethics. It was heavily sedated throughout with tons of thiopental plus ketamine and xylazine.

http://www.youtube.com/watch?v=3FYXYH2ykgc

 

Download the video here

DO NOT USE THESE TECHNIQUES

The only way I recommend performing cricothyrotomy since 2011 is the Bougie-Aided Cricothyrotomy

 

Actual Cric with Old Methods from Youtube

http://www.youtube.com/watch?v=yfyQP4wNbcA

 

My Old Cric Methods

For historical purposes only, here is my video on performing open cricothyrotomy in 3 situations: with a trach set and an assistant, with a trach set when alone, and when you only have a scalpel.

http://www.youtube.com/watch?v=54lG3nFi8eY

 

 

Update: Some of the Stuff Here is now Outdated, Come to Podcast 131 for the cric redux

Ok, Ok, I promise this is the last airway episode for at least a little while. I am perhaps a bit obsessed. Had this show in the works for a while. The cric is the last barrier between a failed airway and death. EM docs need to be able to perform this procedure without hesitation. This requires training and practice until you can perform the procedure in < 30 seconds literally with your eyes closed!

On this show:

Since you need to practice and patients get a wee bit pissed if they wake up with an unnecessary, unexpected tube in their neck, you need something to train on. Pig trachs smell and are not great training IMNSHO. Instead, read this article:

Anaesthesia 2004;59:1012

Here is the picture

With this set-up, which costs nothing, you can practice as many times as necessary any time you like. You'll see my version of the set-up in my video below.

I prefer surgical crics. I think wire-based seldinger kits fail badly when stress is involved. That is opinion. They are also entirely too slow; that is FACT.

Anaesth Anal 2010;110(4):1083 & Anaesthesia 2006;61:565

Here is a video with the three techniques I prefer for crics

Click here to go to the video post

Next we talk to my friend Seth Manoach, another of the ED Intensivist clan. He has a technique for fiberoptic-stylet guided crics.

Click here to see the video

Last, we talk to Darren Braude of airway911.com fame and author of the book Rapid Sequence Intubation & Rapid Sequence Airway. Darren has a technique for bougie-aided cric that you are going to love.

Click here to see the video

photo from wikipedia

.

This lecture refers to the Awake Intubation Lecture

I've been asked, who should be intubated awake. To answer that question, we first must discuss who actually requires intubation. If you wait until the patient is apneic, then of course you can't use awake intubation. The idea is to intubate before the patient stops breathing.

In Ron Walls' airway manual and in his class, he gives the following reasons for intubation:

Crash-a patient who is dead or near dead

Can't Protect Airway

Can't Maintain Ventilation/Oxygenation

Expected decline in Clinical Status

Now some of these make sense and some not so much

Here are my reasons to intubate:

Crash-for me this is any apneic patient

Can't Protect Airway-this one is good, a patient with pooling secretions or obtundation with vomiting buys plastic

Possible Loss of Airway-angioedema, anaphylaxis, neck trauma. These are good reasons to intubate and usually earlier is better and safer.

Oxygenation/Ventilation issues for me mean you intervene. But this doesn't necessarily mean intubation, if the patient has a reversible problem, put them on Non-invasive instead of intubating. See the podcast.

So it all comes down to the last reason

Expected decline-this should be the reason for many ED intubations. If the patient has O2/CO2 issues and they will be getting worse, then consider intubation.

Supply/Demand Imbalance-Last reason, not discussed as often in the ED is severe metabolic acidosis or shock where the lungs are causing a huge metabolic demand in a patient without much supply.

So who can be intubated awake? Any patient except the crash airway can be intubated awake. If you think they are a difficult airway, temporize with NIV while you topically anesthetize and then do the patient awake while they keep breathing.

Who is a difficult airway, there are few good answers.

THe LEMON rule also coined by the Walls crew is probably as good as any:

Look at head and neck

Evaluate 3-3-2

Mallampati

Obstruction

Neck Mobility

see here for more

I also discuss a new possible indication for awake intubation

photo by pig sty ave

Warning-This is not an ED Critical Care Podcast, it is a rant. Rants will be featured periodically and irregularly; feel free to ignore and delete them.

This one was spurred by a post by Chris Nickson, aka precordialthump.

The post led me to an incredible lecture by Dr. David Schriger given at the most recent All LA Conference. You should go and listen to this lecture:

Link to Dr. Schriger's Talk at alllaconference.com

The issue of critical thinking in EM was once dear to my heart. I even wrote a book about it, when I believed that print publishing was not a bloated and dead enterprise.

But the flash and glamor of critical care soon eclipsed my love of critical thinking. However Dr. Schriger's excellent lecture stirred up this old romance.

In this brief rant, I discuss three additional points that occurred to me as I was listening. But remember, you will be far better served using your time to listen to his lecture than my rant.

photo by Rionda

Update:

Click through for Chris Nickson's Take

Young patient, lactate of 5.2, pneumonia... You know what you're supposed to do--put in the central line and start early goal directed therapy. Problem is, most people can't see sticking a central line in a patient that does not need pressors and otherwise looks well. Yet these patient have an annoying habit of going on to decompensate and perish. Well now there may be another way. Thanks to an article just published in JAMA, we may have a path to non-invasive treatment of severe sepsis. In this EMCrit Podcast, I interview Dr. Alan E. Jones, author of the article, Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial. Then I discuss how this article changes the game when it comes to caring for severe sepsis patients.

First, here is the article:

[PubMed]

Dr. Alan Jones was the lead author. He and his co-authors from the EMShockNet, designed a 300-patient randomized, controlled trial in 3 academic emergency departments. Patients were adults with essentially the same entry criteria as the original EGDT study. Both groups received the EGDT protocol except one group got continuous ScvO2 monitoring while the other group got serial lactates. Either serial normal lactates (<2 mmol/L) or a decrease in lactate of greater than or equal to 10% was considered equivalent to an ScvO2 > 70. Lactates that were rising or had cleared < 10% were considered equivalent to ScvO2 < 70. Mortality trended towards a higher rate in the ScvO2 group, but by the predetermined trial parameters, both arms were considered equivalent.

I got a chance to interview Dr. Jones and we talked about the following points:

* Though the trial did not specifically test this strategy, the purpose of the study was to find a path to non-invasive care of severe sepsis.

* Only 10% of the patients in either arm required blood transfusions or inotropes

* In young patients, in certain clinical scenarios, we might move to inotropes before blood, in the Hb 7-10 range.

In addition, Dr. Jones mentioned that in an upcoming preplanned sub-analysis we'll actually get to see if the lactate clearance values and ScvO2 correlated.

I then go on to discuss how this article allows a non-invasive path to managing the young pt with severe sepsis. Let's say we have that young pneumonia patient with a lactate of 5.2

* First, give 2L of the crystalloid of your choice

* Make sure that the SaO2 is > 90%

* Then check the IVC non-invasively with ultrasound.

* IVC < 1.5 cm and has a > 50% collapse with deep inhalation, give more fluid.

* IVC > 1.5 cm and very little collapse, move on

* Confirm that the MAP is still >65, if not then place a central line and do standard EGDT

* Check a repeat lactate. If it cleared ? 10%, then you're done

* If it hasn't transfuse if Hb < 7.

* Give inotropes if Hb > 10 or signs of poor heart function on echo

* Hb 7-10, use your judgment

* Keep trending the lactate

Pushing some ativan followed by vecuronium is no longer an acceptable strategy to manage post-intubation sedation. A good analgesia and sedation package is essential if you care about your patient's comfort and well-being. We need to move to PAIN-FIRST paradigm. Optimize analgesia and then add in sedative agents as a bonus. In this episode of the EMCrit Podcast, I expand on a previous rant to discuss the optimal way to handle routine post-intubation patients and some special scenarios you may encounter.

The Routine

Here is the Lancet Article I mentioned:

(A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial)

Post-Intubation patients are in pain b/c they have a piece of rigid plastic jammed down their throats and b/c we do a lot of evil-seeming stuff to them in the ED.

Give them a bolus of fentanyl or morphine as soon as you complete the intubation (or better yet, with your RSI drugs)

Fentanyl Protocol

Morphine Protocol

Only when you have a calm, relaxed, but fully awake patient, add on a touch of sedative for hypnosis, amnesia, and anxiolysis.

Use a sedation scale like RASS.

Special Scenarios

1. Hypotensive Medical Patient-the patient's blood pressure is never too low to get adequate pain control and sedation. Start them on a pressor and give them comfort. Fentanyl/versed is probably a good combination. Maybe in the future ketamine/versed.

2. Delerium Tremens-these patients need GABA first. My patients have already received 200-400 mg of diazepam before getting intubated so more benzos will probably not help. Use propofol/fentanyl. If propofol is not available, use versed/fentanyl/phenobarbital. Here is a DT protocol that encompasses phenobarb. Also see my DT Podcast.

3. Neurocritically Ill Patients-aka the head bleeds. This one is for Mike, a flight medic. Fentanyl/propofol is the way to go for these patients. Take them deep during the first 24 hours or so. Treat pain and sedation needs first, before add anti-hypertensives; their blood pressure may come down when you treat their pain. If you are transferring these patients, have a very low threshold to intubate, leaving them on propofol/fentanyl. WHen the receiving hospital gets the patient, they can easily extubate them if you used these medications.

Here is my extubation article.

4. Hypotensive Trauma Patients-this pertains to trauma patients hypotensive because of hemorrhagic shock.  I get a bunch of ketamine and a bunch of fentanyl. If their MAP > 65 then I give 25 mcg of fentanyl. Wait a couple of minutes and if still > 65, give some more. If their MAP < 65, I give 10-15 mg of ketamine. Keep going with this until your patient looks good.

Additional References:

Payen JF, Chanques G, Mantz J, Hercule C, Auriant I, Leguillou JL, Binhas M, Genty C, Rolland C, Bosson JL. Current practices in sedation and analgesia for mechanically ventilated critically ill patients: a prospective multicenter patient-based study. Anesthesiology 2007; 106: 687–95.

Rozendaal FW, Spronk PE, Snellen FF, Schoen A, van Zanten AR, Foudraine NA, Mulder PGH, Bakker J. Remifentanil-propofol analgo-sedation shortens duration of ventilation and length of ICU stay compared to a conventional ...

Atrial Fibrillation is a Pain in the Butt

Your patient is pale and diaphoretic. Blood pressure is 70/50. Heart rate is 178. EKG shows atrial fibrillation... What are you going to do???

Yeah, yeah the Pavlovian ACLS response--You cardiovert. Wonderful, except it didn't change a thing. Now what?

In this episode, I discuss the crashing atrial fibrillation patient.

Shock

If the patient is chronically in atrial fib, the shock rarely works. Your patient is unstable, so you decide to give it a shot. You might as well give yourself the best chance of success, so go right for 360 J on monophasic, or equivalently high on your biphasic. This will not cause more injury than lower joules (Heart 1998, 80:3 and Resuscitation 1998;36:193). PA is probably better than AA if you have pads. Make sure the synch is on.

You need to give your patient something to disguise the fact that you are electrocuting them. Yet you don't want to drop their pressure. Ketamine is ok in disassociative dosing, but then your patient is loopy and you lose your mental status exam. Consider 5-7 mg of etomidate along with a pain dose of ketamine, 10-15 mg.

Screen for WPW

If you have a. fib with a wide QRS and a rate > 250-300, be scared, very scared. This is WPW and these patients just love to ruin your day by going into v. fib. Shock early, shock often, light them up.

Get the BP Up

So you made sure it's not WPW and the cardioversion has failed, as it so often does in chronic a. fib. Now you need to raise the BP before anything else. Use push-dose phenylephrine. 50-200 mcg every minute or so until you get the blood pressure above a diastolic of 60; this will temporize the situation and make the patient's heart more likely to slow down.

Though things look better, you have not really fixed the problem, you have just temporized.

Slow them them down

Give either amiodarone 150 mg bolus and then the drip (may repeat the bolus x 1)

Or

Use diltiazem, but not as a push. Drip it in at 2.5 mg/minute until HR < 100 or you get to 50 mg. (Resuscitation 52:167, 2002) See here for more.

Still not working?

* Consider magnesium

* Consider reshocking

* Consider cardiology consult

* Consider something else is going on

* Consider signing out to one of your colleagues and running away

* Consider Ibutilide (See this amazing Steve Smith Post)

Update:

* This study would indicate that perhaps we are doing more harm than good when we aggressively try to control rate or rhythm in stable (non-crashing) patients (Ann Emerg Med 2015;65(5):511)

* LOw dose MAGnesium sulfate versus HIgh dose in the early management of rapid atrial fibrillation: randomised controlled double blind study.  Acad Emerg Med. 2018 Jul 19. doi: 10.1111/acem.13522.

* Wait and See rather than rhythm restoration seems non-inferior1

*

Intubation is a critical procedure, there is no doubt about it.

NIV does not have the glamour; it's not nearly as cinematic. But for the patient, to spend 30 minutes on a NIV mask is preferable to a couple of days on the ventilator. In this episode, I discuss some of the basic ideas and methods of NIV.

It is pretty simple as the mode only has 3 main settings:

FiO2 - set based on oxygen requirements, just like on the vent

PEEP/EPAP/CPAP - all the same thing, set this based on OXYGENATION needs. If the patient's sat is low, start at 5 cm H20 and titrate up to 15-17 as needed.

PSV/IPAP - this setting is for ventilation. If your patient does not have ventilation problems, they don't need PSV. If they do, start at 5 cm H20 and titrate to 15-17.

Yes, that's right, I did not tell you to put every patient at 10/5. Very few of your patients will have both ventilatory and oxygenation problems. Asthma and COPD need inspiratory support. APE, atelectasis, pneumonia patients need PEEP.

I also talk about sedation while a patient is on NIV.