Category: Airway Management
Keywords: Upper GI Bleed, Fistula (PubMed Search)
Posted: 7/27/2009 by Rob Rogers, MD
(Updated: 12/12/2024)
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Aortoenteric Fistula (AEF)-Beware the Upper GI Bleed!
Important points about AEF:
Pearl: Suspect a aortoenteric fistula in any patient with a prior AAA repair who presents with an upper GI bleed (may also be lower GI bleed)
Category: Airway Management
Keywords: Le Fort, fracture, facial (PubMed Search)
Posted: 4/19/2009 by Michael Bond, MD
(Updated: 8/28/2014)
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The French Surgeon Rene Le Fort first described these facial fracture patterns. Reportedly he made the observations after dropping numerous skulls from the wall of a castle. This might be why we don't see pure Le Fort fractures in our patients most of the time as they are not likely to be falling off castle falls head first.
The classic fracture patterns are:
http://radiographics.rsnajnls.org/cgi/content-nw/full/26/3/783/F15
Category: Airway Management
Keywords: Airway (PubMed Search)
Posted: 3/16/2009 by Rob Rogers, MD
(Updated: 12/12/2024)
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Keys to a Successful Intubation
The famous Ken Butler
Category: Airway Management
Keywords: Brugada syndrome (PubMed Search)
Posted: 2/22/2009 by Amal Mattu, MD
(Updated: 12/12/2024)
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Category: Airway Management
Keywords: Intubation, endotracheal intubation, position, laryngoscopy (PubMed Search)
Posted: 8/27/2008 by Ben Lawner, MS, DO
(Updated: 12/12/2024)
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To echo Dr. Rogers' fantastic airway tips:
When considering an intubation or managing an emergent respiratory concern, keep the "P"s of intubation in mind:
1. P osition: No intubating on the floor! Don't get sucked into the patient's oropharynx! Maintain an appropriate distance. Align the airway axes. Sniffing position is utilized for non traumatic adult airways; this involves flexion of the lower c-spine and a bit of extension at the upper cervical levels. Take off cervical collars. Use pillows / blankets to align the external auditory canal (EAC) with the sternal notch to help w/visualization. Cricoid pressure is NOT designed to facilitate passage of the ETT- it MAY help prevent excessive gastric insufflation.
2. P reparation: Two tubes. Two blades. Two intubators. Plan B(ougie) or Plan C(cric). Though your emergency airway plans may differ, think of ALL airways as potentially difficult ones. Respect the epiglottis.
3. P reoxygenation: 100% via NRBM when possible to ensure oxygenation and nitrogen washout. In patinets with at least some reserve, this will help to avoid pulse ox pitfalls. True RSI does NOT involve positive pressure ventilation.
4. P remedication: Know your sedatives in advance. Etomidate ? Ketamine ? Diprivan ? Whatever your agent of choice, know indications and drug dosages. Emergent RSI is a less than ideal time to access Epocrates.
5. P aralysis: This is pretty much the point of no return. Administration of paralytics commits you to securing a patient's airway. Both rocuronium and succynylcholine can be dosed at 1 mg/kg IV.
6. P ass the tube: What Dr. Rogers said.
7. P osition confirmation: Direct visualization of the tube through the glottic opening coupled with end tidal Co2 is ideal.
-Our very own Dr. Ken Butler: "Be prepared!"
Category: Airway Management
Keywords: laryngoscopy (PubMed Search)
Posted: 8/26/2008 by Rob Rogers, MD
(Updated: 12/12/2024)
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Quick Pearls for Intubating:
1. When intubating, make sure to use two hands!
2. Resist the urge to look for cords
3. Stylet shape is crucial
1. Our very own Ken Butler
2. Rich Levitan-Airway Course
Category: Airway Management
Keywords: Pregnancy, Pulmonary Embolism (PubMed Search)
Posted: 6/30/2008 by Rob Rogers, MD
(Updated: 12/12/2024)
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Pregnancy and Acute Pulmonary Embolism
Women who are pregnant or in the postpartum period and women who take hormonal therapy are at an increased risk of pulmonary embolism.
Some facts:
Tapson V. Acute Pulmonary Embolism. N Engl J Med 2008;358:1037-52
Category: Airway Management
Keywords: Thrombolytic, Pulmonary Embolism (PubMed Search)
Posted: 6/16/2008 by Rob Rogers, MD
(Updated: 12/12/2024)
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Thrombolytic Therapy for PE Mike Abraham and I had a very interesting PE case a few nights ago: 30's yo female presented with a two week history of slow onset, progressive DOE. Initially placed in the asthma room because she had a history of asthma. CXR negative. ECG inverted precordial T-waves and S1Q3T3. CT showed massive central, saddle embolus. Troponin 1.2. Normal BP and a pulse of 110. The patient actually laughed when informed of her diagnosis. She was admitted to the PCU. Now, let me share with you how big her clot burden was...it was huge. Biggest I have seen in years. Approximately 70% or so of her total pulmonary circulation was occluded! And, she was laughing. Her BP, though, was never low. The question came up: is this patient a candidate for thrombolytics? After all, she wasn't unstable. Our plan in the ED was to administer tPA based on her clot burden, but she was admitted quickly to the PCU in stable condition and they continued the workup and therapy. Considerations for giving lytics to a PE patient:
Tapson V, Up To Date, July 2007
Kline J, Journal of Thrombosis and Hemostasis, 2008
Category: Airway Management
Keywords: Asthma (PubMed Search)
Posted: 2/18/2008 by Rob Rogers, MD
(Updated: 12/12/2024)
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Care of the Crashing Asthma Patient
Several things should be considered in the crashing asthmatic:
Category: Airway Management
Keywords: TBI, Traumatic Brain Injury, Head CT (PubMed Search)
Posted: 10/18/2007 by Aisha Liferidge, MD
(Updated: 12/12/2024)
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According to ACEP's clinical policy, a non-contrast head CT is only indicated in mild traumatic brain injury under the following circumstances:
1) headache
2) vomiting
3) age over 60
4) drug or alcohol intoxication
5) short-term memory deficits
6) physical evidence of injury above the clavicle
7) seizure
Category: Airway Management
Keywords: Intubation, Bougie, Difficult Airway, Wound Care, Irrigation (PubMed Search)
Posted: 7/10/2007 by Michael Bond, MD
(Updated: 12/12/2024)
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Category: Airway Management
Keywords: Airway, Intubation (PubMed Search)
Posted: 7/12/2007 by Michael Bond, MD
(Updated: 12/12/2024)
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Category: Airway Management
Keywords: Intubation, Airway (PubMed Search)
Posted: 7/12/2007 by Michael Bond, MD
(Updated: 12/12/2024)
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Category: Airway Management
Keywords: Plateau, Peak, Pressure, airway (PubMed Search)
Posted: 7/14/2007 by Mike Winters, MBA, MD
(Updated: 12/12/2024)
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Category: Airway Management
Keywords: Air, Embolism, Catheter (PubMed Search)
Posted: 7/14/2007 by Mike Winters, MBA, MD
(Updated: 12/12/2024)
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Category: Airway Management
Keywords: RSI, Preoxygenation (PubMed Search)
Posted: 9/13/2016 by Rory Spiegel, MD
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During rapid sequence intubation (RSI) we endeavor to avoid positive pressure ventilation, prior to securing a definitive airway. As such, an adequate buffer of oxygen is necessary to ensure a safe apneic period. This process involves replacing the residual nitrogen in the lung with oxygen. It has been demonstrated that a standard nonrebreather (NRB) mask alone does not provide a high enough fractional concentration of oxygen (FiO2) to optimally denitrogenate the lungs (1). Even when a nasal cannula at 15L/min is utilized in addition to the NRB, the resulting FiO2 is not ideal. A bag-valve mask (BVM) with a one-way-valve or PEEP valve has been demonstrated to provide oxygen concentrations close to that of an anesthesia circuit. But its effectiveness is drastically reduced if a proper mask seal is not maintained during the entire pre-oxygenation period (1). This is not always logistically possible in the chaos of an Emergency Department intubation.
A standard NRB with the addition of flush-rate oxygen appears to be a viable alternative. Recently published in Annals of Emergency Medicine, Driver et al demonstrated that a NRB with wall oxygen flow rates increased to maximum levels, rather than the standard 15L/min, provided end-tidal O2 (ET-O2) levels similar to an anesthesia circuit (2).
1. Hayes-bradley C, Lewis A, Burns B, Miller M. Efficacy of Nasal Cannula Oxygen as a Preoxygenation Adjunct in Emergency Airway Management. Ann Emerg Med. 2016;68(2):174-80.
2. Driver BE, Prekker ME, Kornas RL, Cales EK, Reardon RF. Flush Rate Oxygen for Emergency Airway Preoxygenation. Ann Emerg Med. 2016;