FOAMfrat Podcast

This mini episode is meant to cover the logistics of setting up your induction & post procedure sedation package. Our poison of choice is obviously Ketamine because of its panoply of sexy advantages when it comes to DSI.

In a very simplified approach to ventilation we can separate our vent strategies into either an obstructive or injury patient. Obstructive patients are known to have an increased amount of effort on the exhalation phase of the respiratory cycle. Exhalation is a passive phase of breathing and when a reduction in airway caliber occurs, there is little recruitment of muscle to assist in the process. A putative practice is to reasonably reduce the minute volume and increase the exhalation time. With the obstructive patient already having an underlying pathology that causes carbon dioxide (c02) retention, the reduction in minute volume is usually well tolerated. The injury patient is essentially for everyone else. In an attempt to reduce the frequency of barotrauma and acute lung injury, evidence suggests the routine use of lower tidal volumes (Vt). A standard practice is to start off around 6-8cc/kg of IBW. This strategy is the go-to method for patients presenting with decrease lung compliance due to infiltrates and in the worst case scenario Acute Respiratory Distress Syndrome (ARDS). The clinician usually battles the task of adequate oxygenation in this subset. Recruitment maneuvers are performed in an attempt to increase the surface area for gas exchange. These techniques are performed with inspiratory maneuvers, and maintained with PEEP. I believe we have seen vast improvement in the way we care for each of these disease processes. I don’t think we have opened up enough dialogue as to how to approach when these two pathologies collide. Before You Touch The Ventilator: There are a series of thought processes one must intuitively execute before we initiate a ventilator strategy. The first is recognizing that the sicker the patient is, the wide the pulse ox latency will be. A healthy individual will have an approx. 30 second lag from central to peripheral circulation. This increases as hemodynamics deteriorate. It is not uncommon for a septic patient to have over a 2 minute lag time. What does this mean for you? Don’t expect abrupt changes in oxygenation after each turn of the dial. A good practice is to allow two minutes between an adjustment and a response. For example, if I set my positive end expiratory pressure (PEEP) to 10, I shouldn’t briskly crank it to 15 without allowing an appropriate amount of time. Get in the habit of figuring out your PaC02/ETc02 gradient. Unless you are able to analyze blood gas values on transport, this is your time to figure out what your Knowing that the COPD patient lives off of a hypoxic drive, we can reasonably conclude that a saturation of 90% is a good goal for oxygenation. With an assumed right shift on the oxyhemoglobin disassociation curve, this would require a Pa02 of approx. 90-100 mmhg. The Strategy: To initiate this strategy we are assuming the patient is hypoxic and hypercapneic. Step 1. Start with 6cc’s /kg of IBW & Frequency of 12 bpm. Fi02 should be set at 1.0. Step 2. Auto Peep and Pplat should be assessed. Step 3. Set extrinsic PEEP to 75% of Auto Peep. This will aid in stenting open the terminal bronchiole and make up for diseased elastin. Preventing cyclic opening is a secondary benefit of this approach. Step 4. If VTE is < 50% of desired VT increase I time to 2 seconds for 2 minutes and watch for VTE to increase. This is a 5 second total cycle time and at a respiratory rate of 12 will give you a 2:3 ratio. Step 5. If after two minutes your VTE is at least 75% of your target Vt, dial the I time back to 1 second and maintain recruitment with PEEP.

You have heard me brag about the critical care refresher that Lifestar puts on every two years. This is a clip by Dr. Lorin Browne. He is the Assistant Professor of Pediatrics and Emergency Medicine at Children's Hospital of Milwaukee. He is also one of the coolest dudes I have had the opportunity to hang out with. In this small clip he discusses why cyanosis will not always be an outward sign of adequate oxygenation. Towards the end of this podcast he refers to a website he uses routinely for staying fresh on congenital heart defects. Here is that link https://www.cincinnatichildrens.org/patients/child/encyclopedia/defects . http://blog.cincinnatichildrens.org/rare-and-complex-conditions/heart-conditions/animated-videos-illustrate-congenital-heart-defects/

Here it is! The series finale of "Tips For The Occasional Intubator". Tip 5. Video Laryngoscopy It’s no doubt that video laryngoscopy (VL) is sweeping the nation. While there are some resistors, the majority of providers have moved towards utilizing VL for their routine intubations. The VL tool comes in many shapes and sizes, and each one provides a little something different. Hyper-angulated blades allow you to “peak” around the corner with very little displacement of tissue. The standard geometry blade allows you to use the tool like DL, but optimize your view and allow your colleagues to see what you see. For these reasons, I have personally adopted VL into my routine practice. I have seen the success rates of my service DRASTICALY improve with this addition. I have seen some studies that show no difference between DL & VL. My only argument against these studies, is that the services that are cooperating in the study have high exposure to intubations. The question isn’t whether VL is better than DL, but rather are we practiced enough to effectively use DL. Tip 6. Simulation “The mannequin is nothing like the real thing!” This phrase comes out of most student’s mouth as they walk out of the operating room after clinicals. The truth is, they’re right! But, I don’t think the actual procedure of intubating is that difficult, and it’s certainly not the most dangerous. The part that we need to practice is the steps leading up to intubation, and the monitoring afterwards. No one dies from someone missing a tube and recognizing it right away. People die when the heuristics and planning fail to recognize failure. Guess what? This part we can simulate! Students routinely go into the OR and nail an intubation under the proper set up of an anesthesiologist. It’s required to complete clinicals! This right here tells me that we are capable of performing the skill, we just need help with knowing when to do it, and optimizing the conditions we perform it in. So there you have it… Our 6 tips that I have adopted into my occasionally intubating first pass success.

You came back for part two! In this episode Dr. Jeff Jarvis and I discuss his system's technique for pre-oxygenation, and why pre-loading your bougie can help increase your first pass success. Tip 3. NODESAT! “Nasal Oxygen During Efforts To Secure a Tube” (NODESAT) is a term coined by Rich Levitan in regards to placing a nasal cannula at high flow on a patient during the pre-ox and intubation process. This allows not only augmentation of FI02 from a NRB or BVM, but also the ability to provide apneic oxygenation during intubation. The idea is during the pre-ox period you place a NC at 15lpm, a NRB at 15lpm, and try to achieve an SP02 of 100 % for at least 3 minutes prior to intubation. Because this provides little positive pressure, it will likely not work in a patient with physiological shunting. If you HAVE to ventilate a patient due to inadequate peri-intubation ventilation, then the use of CPAP or BVM with a PEEP valve will be needed. By utilizing Henry’s law we can not only increase the surface area of alveoli by recruitment, but also apply pressure to the oxygen to assist in diffusion. Tip 4. Ditch The Stylet! I may be crucified by some for saying this, but statistics and anecdotal experience has shown you are much more likely to achieve first pass success if you utilize a bougie. Now the old way that we were taught to use the bougie required two people to perform. One person would intubate the trachea with the bougie, and the other would assist in railroading an ET tube over the bougie. A more common and efficient trick in the pre-hospital realm, is to preload the bougie with either a Kiwi grip or D grip. The cudae tip allows for easier anterior access, and the tactile feel of the bougie allows you to feel the tracheal rings upon successful placement. The bougie is commonly used as an emergency tool for difficult airways. If we are intubating a patient, it is an emergency, and we need to use everything possible to optimize our FPS. The occasional intubator recognizes the need to utilize every strategy possible to achieve their goal. A study showed providers increased their FPC success rates from 66% to 96% just by utilizing the bougie. This is a must in every pre-hospital airway kit. Sources: Comparison of the stylet and the gum elastic bougie in tracheal intubation in a simulated difficult airway Riaz Ahmed Khan*,Farah Ashraf Khan **, Muhammad Azam*** Anaesthesia, Pain & Intensive Care ISSN 1607-8322, ISSN (Online) 2220-5799

Dr. Jeff Jarvis joins me in this three part series on tips to optimize your first pass success with intubation.... but now just for any one, this podcast is for "The Occasional Intubator". Let’s face it, as Paramedics we don’t walk around every shift throwing tubes down everyone’s throat! We have to realize that this is a skill that has the potential to save someone’s life, but also has the potential to take one. There have been rumblings back and forth on whether medics should be allowed to perform a skill they don’t use frequently. These arguments are backed by scenarios where providers have failed intubation, intubated the goose, and never used any quantifiable markers to validate placement….. and the patient died. Can we honestly use this as an argument to take away the skill of endotracheal intubation at the Paramedic level? Let’s address this question with some very reasonable concerns that come up regarding airway management training in Paramedic school. With so much to cover in a short period of time, airway management does not get NEAR the time it deserves in our initial education. We are taught that an RSI is a lighting speed process, we are told to hold our breath and when we need to breathe, it’s time to get out! We are led to believe that we will dip the blade into the hypopharynx and immediately see the cords!! These teachings create a nervous and jittery intubator who isn’t breathing because some clown told him to hold his breath! There competency is validated by their ability to perform five intubations in a nicely lit, controlled environment. Under the heuristics and proper set up of an anesthesiologist. So now you are probably wondering… where are the tips?? This just seems like a dig at formal paramedic education! The first tip is to realize that you are an “occasional intubator”. Don’t let that discourage you though, because you can achieve excellence with this skill, you just need to put all the odds in your favor. Tip 1. Positioning 99% of the time in school you will be intubating mannequin heads that are stuck to a flat board. You will find yourself bending down low and trying to get eye level with the larynx axis. Finger tips turn white as you struggle to lift forward enough to see the cords, while trying to not use the teeth as a fulcrum. There are three axis we need to become familiar with when intubating. The oral, pharyngeal, and laryngeal axis. These can easily be aligned by putting the patient in an ear to sternal notch position. When applied properly, you really only need the laryngoscope to lift the tongue out of the way. This technique in cooperation with airway adjuncts also helps optimize First Pass Ventilation (FPV) with a BVM. The saying “work smarter, not harder” really applies simply to the way you position your patient. Tip 2. Delay Your Sequence Intubation is not a game of speed. Get scene times out of your head for a minute and realize that speed means nothing when you deliver a hypoxic patient in peri-arrest. Delayed Sequence Intubation (DSI) is procedural sedation, with the procedure being pre-oxygenation. If you are intubating a hypoxic patient, you are setting yourself up for failure. Take the time to properly pre-oxygenate & denitrogenate your patient. This usually takes about 3 minutes to perform…. Can you wait that long? It may seem like FOREVER, but trust me it will give you a safety net during intubation. The goal of the peri-intubation period is to have the patient spontaneously breathing as much as possible up until the point of intubation. This prevents excessive bagging, gastric insufflation, and some of the negative effects of BVM ventilation. Most induction agents will depress your respiratory drive such as versed, etomidate, fentanyl, etc. So how do we keep this breathing adequately up until the point of intubation?

VIOLET.. YOUR TURNING VIOLET! What patients are at risk for IAH or ACS? Is this something I should be measuring?! These questions and more are discussed when I bring back on the show my friend Kyle Driesse. References: Guidelines from the World Society of Abdominal Compartment Syndrome. https://wsacs.org/education.html Mechanical ventilation and intra-abdominal hypertension: 'Beyond Good and Evil' Crit Care. 2012; 16(6): 187. Published online 2012 Dec 18. doi: 10.1186/cc11874 Leave questions or comments below! Thanks for listening.

This was a lecture I gave at Lifestar this month on the logistics of a pediatric arrest. During this talk I list five aspects to consider before you are center stage. Hope you enjoy!

FOAMed has completely changed the way we learn. Dry boring topics are now infused with enthusiastic lectures an evidence based practice. This podcast discusses the vital roles of our world.