Patient Safety - האיגוד הישראלי לרפואה דחופה

Patient Safety - האיגוד הישראלי לרפואה דחופה

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Patient Safety - האיגוד הישראלי לרפואה דחופה episodes

  • PODCAST: Airway Management in TBI or Ischemia
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    Try Alex (chatbot in right lower corner of the website)

    Evidence-based, fully-referenced answers

    ​Airway Management in TBI or Ischemia​

    Published on September 1, 2025

     

    Written by Vivian Lei


    This is a concise, evidence-based approach to intubating patients with acute brain injury while minimizing secondary brain injury and preserving cerebral perfusion.

    Mindful Intubation

    Emergency airway management in patients with acute brain injury or ischemia poses unique challenges, with a risk of causing secondary brain injury. Here’s how to optimize outcomes in this high-risk population.

    • Primary goal- Prevent secondary brain injury from hypoxia, hypotension, hyper/hypocarbia, or increased intracranial pressure (ICP).
      • Before intubation-
        • Perform a rapid but thorough neurological exam (GCS, pupils, motor function, speech).
        • Optimize oxygenation with preoxygenation (NRB, HFNC, NIPPV, or BVM) and apneic oxygenation.
        • Avoid hypotension. Maintain MAP 80–100 mmHg. Individualize based on the patient’s baseline BP.
        • Address suspected ICP elevation while preserving cerebral perfusion pressure (CPP). Elevate head of bed 30°, avoid jugular compression, ensure proper cervical collar fit.
          • During intubation-
            • Consider fentanyl (2–3 mcg/kg) as a sympatholytic to blunt laryngoscopy response when safe. Lidocaine is not recommended.
            •  Use rapid-sequence induction (RSI) with hemodynamically neutral agents, such as etomidate or ketamine (now considered safe and may reduce ICP).
            • Succinylcholine is preferred for shortened paralysis unless there is a contraindication. Rocuronium is acceptable with awareness of prolonged effect.
            • Maintain eucapnia during BVM via waveform capnography.
            • Video laryngoscopy is recommended to improve first-pass success and reduce complications.
              • After intubation-
                • Set ventilator settings for pH 7.3–7.4, PCO2 35–45 mmHg, SpO2 >95%, tidal volume 6-8 cc/kg, and initial PEEP of 5-8 cmH20.
                • Reserve hyperventilation (target PCO2 30–35 mmHg) for brief ICP crisis management, paired with ICP lowering therapy (hypertonic saline, mannitol).
                • Provide adequate analgesia and sedation to prevent agitation and ICP spikes.
                  • Propofol + fentanyl is preferred if hemodynamically stable. Consider adding low-dose vasopressor (e.g. norepinephrine) for mild hypotension.
                  • Use midazolam if significant hypotension.
                  • Ketamine or dexmedetomidine are useful as adjuncts for patients requiring multiple sedative agents.
                  •  Delay antihypertensives until after pain/anxiety is addressed to avoid hypotension.
                  •  Initiate continuous EEG when possible to detect non-convulsive seizures.

                    • How does this change my practice?

                    The practical framework provided in this article stresses the importance of individualizing the approach to each brain-injured patient, with the goal of minimizing secondary brain injury. This allows a physician to consider the nuance of pharmacologic strategies (ketamine is OK!), intubation techniques (VL>DL), and post-intubation considerations (sedation first, consider EEG).

                    Source

                    Airway Management in Patients With Acute Brain Injury or Ischemia. J Emerg Med. 2025 Jul;74:125-133. doi: 10.1016/j.jemermed.2024.12.015. Epub 2025 Jan 6. PMID: 40348691

                    The post PODCAST: Airway Management in TBI or Ischemia first appeared on האיגוד הישראלי לרפואה דחופה.

                    4 min
                  • PODCAST: Acute Agitation

                    We’re back with another episode of Push Dose Pearls with ED Clinical Pharacist, Haley Burhans! In this episode, we break down the essentials of managing agitation in the ED—starting with why you should avoid diphenhydramine in the elderly and benzodiazepines in the 3 D’s: drunk, delirium, and dementia. We discuss how to quickly assess the cause, choose the right medication, and decide between IM and IV routes. And Haley offers some key safety tips and considerations for special populations, including kids and the elderly. 

                    Was this episode helpful? What other medications would you like to learn more about? Hit us up on social media @empulsepodcast or at ucdavisem.com

                    Hosts:

                    Dr. Julia Magaña, Professor of Pediatric Emergency Medicine at UC Davis

                    Dr. Sarah Medeiros, Professor of Emergency Medicine at UC Davis

                    Guests:

                    Haley Burhans, PharmD, Emergency Medicine Clinical Pharmacist at UC Davis

                    Resources:

                    ACEP’s New Clinical Policy on Severe Agitation. By Molly E.W. Thiessen, MD, FACEP | on February 12, 2024

                    Pediatric Education and Advocacy Kit (PEAK): Agitation

                    Hoffmann JA, Pergjika A, Konicek CE, Reynolds SL. Pharmacologic Management of Acute Agitation in Youth in the Emergency Department. Pediatr Emerg Care. 2021 Aug 1;37(8):417-422. doi: 10.1097/PEC.0000000000002510. PMID: 34397677; PMCID: PMC8383287.

                    Gerson R, Malas N, Feuer V, Silver GH, Prasad R, Mroczkowski MM. Best Practices for Evaluation and Treatment of Agitated Children and Adolescents (BETA) in the Emergency Department: Consensus Statement of the American Association for Emergency Psychiatry. West J Emerg Med. 2019 Mar;20(2):409-418. doi: 10.5811/westjem.2019.1.41344. Epub 2019 Feb 19. Erratum in: West J Emerg Med. 2019 May;20(3):537. doi: 10.5811/westjem.2019.4.43550. Erratum in: West J Emerg Med. 2019 Jul;20(4):688-689. doi: 10.5811/westjem.2019.4.44160. PMID: 30881565; PMCID: PMC6404720..

                    ****

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                    21 min
                  • PODCAST: Airway to Heaven- A Primer on Mechanical Ventilation for Emergency Providers
                    Saturday Jul 05, 2025

                    Dr. Harish Kinni, a triple-board-certified emergency medicine and critical care physician and assistant professor at the Mayo Clinic, provides an overview of the fundamentals of ventilator care for emergency department professionals. We will review key modes that we should know, the variables to set, how to adjust them for your patient’s needs, and provide troubleshooting tips and tricks for when things suddenly go awry. This is sure to be one of the most helpful chapters of Always on EM, but don’t let it take your breath away!

                    CONTACTS

                    X – @AlwaysOnEM; @VenkBellamkonda

                    YouTube – @AlwaysOnEM; @VenkBellamkonda

                    Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch

                    REFERENCES & LINKS

                    • Swart P, Nijbroek SGLH, Paulus F, Neto AS, Schultz MJ. Sex Differences in Use of Low Tidal Volume Ventilation in COVID-19-Insights From the PRoVENT-COVID Study. Front Med (Lausanne). 2022 Jan 3;8:780005. doi: 10.3389/fmed.2021.780005. PMID: 35300177; PMCID: PMC8923734.
                    • McNicholas BA, Madotto F, Pham T, Rezoagli E, Masterson CH, Horie S, Bellani G, Brochard L, Laffey JG; LUNG SAFE Investigators and the ESICM Trials Group. Demographics, management and outcome of females and males with acute respiratory distress syndrome in the LUNG SAFE prospective cohort study. Eur Respir J. 2019 Oct 17;54(4):1900609. doi: 10.1183/13993003.00609-2019. PMID: 31346004.
                    • Swart P, Deliberato RO, Johnson AEW, Pollard TJ, Bulgarelli L, Pelosi P, de Abreu MG, Schultz MJ, Neto AS. Impact of sex on use of low tidal volume ventilation in invasively ventilated ICU patients-A mediation analysis using two observational cohorts. PLoS One. 2021 Jul 14;16(7):e0253933. doi: 10.1371/journal.pone.0253933. PMID: 34260619; PMCID: PMC8279424.
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                    • Fan E, Del Sorbo L, Goligher EC, Hodgson CL, Munshi L, Walkey AJ, Adhikari NKJ, Amato MBP, Branson R, Brower RG, Ferguson ND, Gajic O, Gattinoni L, Hess D, Mancebo J, Meade MO, McAuley DF, Pesenti A, Ranieri VM, Rubenfeld GD, Rubin E, Seckel M, Slutsky AS, Talmor D, Thompson BT, Wunsch H, Uleryk E, Brozek J, Brochard LJ; American Thoracic Society, European Society of Intensive Care Medicine, and Society of Critical Care Medicine. An Official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine Clinical Practice Guideline: Mechanical Ventilation in Adult Patients with Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med. 2017 May 1;195(9):1253-1263. doi: 10.1164/rccm.201703-0548ST. Erratum in: Am J Respir Crit Care Med. 2017 Jun 1;195(11):1540. doi: 10.1164/rccm.19511erratum. PMID: 28459336.
                    • Alhazzani W, Møller MH, Arabi YM, Loeb M, Gong MN, Fan E, Oczkowski S, Levy MM, Derde L, Dzierba A, Du B, Aboodi M, Wunsch H, Cecconi M, Koh Y, Chertow DS, Maitland K, Alshamsi F, Belley-Cote E, Greco M, Laundy M, Morgan JS, Kesecioglu J, McGeer A, Mermel L, Mammen MJ, Alexander PE, Arrington A, Centofanti JE, Citerio G, Baw B, Memish ZA, Hammond N, Hayden FG, Evans L, Rhodes A. Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19). Crit Care Med. 2020 Jun;48(6):e440-e469. doi: 10.1097/CCM.0000000000004363. PMID: 32224769; PMCID: PMC7176264.
                    • Wang W, Scharfstein D, Wang C, Daniels C, Needham D, Brower R, NHLBI ARDS Clinical Network. Estimating the Causal Effect of Low Tidal Volume Ventilation on Survival in Patients with Acute Lung Injury. J R Stat Soc Ser C Appl Stat. 2011. PMC: PMC3197806
                    • Brower RG, Thompson BT, NIH/NHLBI/ARDSNetwork. Tidal volumes in acute respiratory distress syndrome–one size does not fit all. Crit Care Med. 2006.
                    • Hager DN, Krishman JA, Hayden D, Brower RG, ARDSNet NIH / NHLBI. Tidal Volume Reduction in Patients with acute Lung Injury When Plateau Pressures Are Not High. Am J Resp Crit Care Med. 2005.
                    • Rubenfeld GD, Cooper C, Carter G, Thompson BT, Hudson LD. Barriers to providing lung protective ventilation to patients with acute lung injury. Crit Care Med. 2004.
                    • Chatburn RL, El-Khatib M, Mireles-Cabodevila E. A taxonomy for mechanical ventilation: 10 fundamental maxims. Respir Care. 2014 Nov;59(11):1747-63. doi: 10.4187/respcare.03057. Epub 2014 Aug 12. PMID: 25118309.
                    • Guo L, Wang W, Zhao N, Guo L, Chi C, Hou W, Wu A, Tong H, Wang Y, Wang C, Li E. Mechanical ventilation strategies for intensive care unit patients without acute lung injury or acute respiratory distress syndrome: a systematic review and network meta-analysis. Crit Care. 2016 Jul 22;20(1):226. doi: 10.1186/s13054-016-1396-0. PMID: 27448995; PMCID: PMC4957383.
                    • Rice TW, Wheeler AP, Bernard GR, Hayden DL, Schoenfeld DA, Ware LB, NIH NHLBI ARDS Network. Comparison of the Sp02/FI02 Ratio and the PaO 2/FI02 in Patients with Acute Lung Injury or ARDS. Chest. 2007.
                    • Zhang G, Burla MJ, Caesar BB, Falank CR, Kyros P, Zucco VC, Strumilowska A, Cullinane DC, Sheppard FR. Emergency Department SpO2/FiO2 Ratios Correlate with Mechanical Ventilation and Intensive Care Unit Requirements in COVID-19 Patients. West J Emerg Med. 2024 May;25(3):325-331. doi: 10.5811/westjem.17975. PMID: 38801037; PMCID: PMC11112664.

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                      1 hr 14 min

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